Provider Demographics
NPI:1376535807
Name:BRAVO, JOSEPH JAVIER (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:JAVIER
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 636324
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6324
Mailing Address - Country:US
Mailing Address - Phone:859-334-5555
Mailing Address - Fax:859-334-5552
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2000
Practice Address - Fax:859-301-5690
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY186502086S0129X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0356798Medicaid
KY64186505Medicaid
OH0356798Medicaid
KY64186505Medicaid
KY0655050Medicare PIN
KY3313140Medicare PIN
KY020035721Medicare PIN