Healthcare Provider Details

I. General information

NPI: 1215140900
Provider Name (Legal Business Name): PACO EDUARDO BRAVO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

IV. Provider business mailing address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-3000
  • Fax:
Mailing address:
  • Phone: 215-662-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberMD462995
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: