Basic Information
| Provider Information | |||||||||
| NPI: | 1013044718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAVO | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 RIO GRANDE ST STE 348 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123248960 | ||||||||
| FaxNumber: | 5123248962 | ||||||||
| Practice Location | |||||||||
| Address1: | 313 E 12TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123248960 | ||||||||
| FaxNumber: | 5123248962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | G4853 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | G4853 | 01 | TX | LICENSE | OTHER |