Healthcare Provider Details

I. General information

NPI: 1104018217
Provider Name (Legal Business Name): FRANCISCO EFRIAN BRAVO JR MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 E DOWNING ST
TAHLEQUAH OK
74464-3014
US

IV. Provider business mailing address

302 E DOWNING ST
TAHLEQUAH OK
74464-3014
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-0655
  • Fax: 918-456-1356
Mailing address:
  • Phone: 918-456-0655
  • Fax: 918-456-1356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number19440
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. FRANCISCO EFRIAN BRAVO JR.
Title or Position: OWNER
Credential: MD PC
Phone: 918-456-0655