Healthcare Provider Details

I. General information

NPI: 1386644383
Provider Name (Legal Business Name): MIQUEL A BRAVO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S JAMES ST
DOVER OH
44622-3206
US

IV. Provider business mailing address

420 S JAMES ST
DOVER OH
44622-3206
US

V. Phone/Fax

Practice location:
  • Phone: 330-602-7707
  • Fax: 330-602-6071
Mailing address:
  • Phone: 330-602-7707
  • Fax: 330-602-6071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number52476
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: