Provider Demographics
NPI:1326139676
Name:BRAVO, ANTONIO J (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:J
Last Name:BRAVO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANTONIO
Other - Middle Name:JESUS
Other - Last Name:BRAVO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4201 WINFIELD RD FL 4
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-4025
Mailing Address - Country:US
Mailing Address - Phone:331-221-6377
Mailing Address - Fax:331-221-2357
Practice Address - Street 1:133 E BRUSH HILL RD STE 308
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-5662
Practice Address - Country:US
Practice Address - Phone:331-221-9006
Practice Address - Fax:331-221-2734
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-078936207V00000X
IL036078936207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36078936Medicaid
IL036078936Medicaid
IL36078936Medicaid
IL536400Medicare PIN