Provider Demographics
NPI:1386642361
Name:BRAVYAK, JAMES G (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:G
Last Name:BRAVYAK
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 1:102E CENTRE BLVD
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4129
Mailing Address - Country:US
Mailing Address - Phone:856-988-6260
Mailing Address - Fax:856-988-6270
Practice Address - Street 1:102 CENTRE BLVD
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4129
Practice Address - Country:US
Practice Address - Phone:856-988-6260
Practice Address - Fax:856-988-6270
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB44832207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2410702Medicaid
NJ2410702Medicaid
NJ402329Medicare ID - Type Unspecified