Provider Demographics
NPI:1346683018
Name:BRAVERMAN, MAXWELL ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:ALLEN
Last Name:BRAVERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4402
Mailing Address - Country:US
Mailing Address - Phone:210-358-2078
Mailing Address - Fax:210-358-1972
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-2078
Practice Address - Fax:210-358-1972
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC7-0005355208600000X
TXR5517208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX388513901Medicaid
TX388513902OtherCSHCN