Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207NS0135X | Procedural Dermatology | ME74194 | FL |
N | 207Q00000X | Family Doctor | ME-74194 | FL |
NPI | 1558470443 |
---|---|
Provider Name | Juan Oscar Bravo |
First Address | Plant City, FL 33563-5403 |
Second Address | Plant City, FL 33563-5403 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 24/03/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
271611900 | (05) | FL |
44573 | BCBS (01) | FL |
G64819 | (02) | FL |