Provider Demographics
NPI:1225011281
Name:BRAVO, STEPHEN M (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:BRAVO
Suffix:
Gender:M
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 690909
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32869-0909
Mailing Address - Country:US
Mailing Address - Phone:407-363-2772
Mailing Address - Fax:407-745-2844
Practice Address - Street 1:9350 TURKEY LAKE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7319
Practice Address - Country:US
Practice Address - Phone:407-363-2772
Practice Address - Fax:407-745-2844
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME834992085R0202X
NY2167682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267291000Medicaid
FL80038OtherBC BS OF FLORIDA
FL267291000Medicaid
G65761Medicare UPIN
FL80038OtherBC BS OF FLORIDA