Provider Demographics
NPI:1083651657
Name:BRAVO, JAN S (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:S
Last Name:BRAVO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4419
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-4419
Mailing Address - Country:US
Mailing Address - Phone:888-620-3100
Mailing Address - Fax:818-587-2493
Practice Address - Street 1:2105 FOREST AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1425
Practice Address - Country:US
Practice Address - Phone:408-947-2500
Practice Address - Fax:818-587-2493
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43844207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A438440OtherBLUE SHIELD
CA00A438440Medicaid
CA00A438440Medicaid
CA00A438440Medicare ID - Type Unspecified