Basic Information
| Provider Information | |||||||||
| NPI: | 1730578774 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WOUND & SKIN EXPERTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 S ALEXANDER ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | PLANT CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335638415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137547756 | ||||||||
| FaxNumber: | 8137547565 | ||||||||
| Practice Location | |||||||||
| Address1: | 1514 S ALEXANDER ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | PLANT CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335638415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137547756 | ||||||||
| FaxNumber: | 8137547565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2015 | ||||||||
| LastUpdateDate: | 08/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | BRAVO | ||||||||
| AuthorizedOfficialFirstName: | JUAN | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8633988362 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2083P0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 014765700 | 05 | FL | MEDICAID |