Basic Information
| Provider Information | |||||||||
| NPI: | 1558470443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRAVO | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | OSCAR | ||||||||
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| Credential: | MD, CWS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 S EVERS ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | PLANT CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335635403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137547756 | ||||||||
| FaxNumber: | 8137547565 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 S EVERS ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | PLANT CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335635403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137547756 | ||||||||
| FaxNumber: | 8137547565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 03/24/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | ME74194 | FL | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207Q00000X | ME-74194 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 2083P0011X | ME74194 | FL | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 271611900 | 05 | FL | MEDICAID | 44573 | 01 | FL | BCBS | OTHER |