Provider Demographics
NPI:1407864465
Name:BRAVO EDORA, FLORESITA B (MD)
Entity Type:Individual
Prefix:
First Name:FLORESITA
Middle Name:B
Last Name:BRAVO EDORA
Suffix:
Gender:F
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 373
Mailing Address - Street 2:135 SOUTH PENN AVENUE
Mailing Address - City:HARRISVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26362-0373
Mailing Address - Country:US
Mailing Address - Phone:304-643-4005
Mailing Address - Fax:304-643-4007
Practice Address - Street 1:135 SOUTH PENN AVENUE
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:WV
Practice Address - Zip Code:26362-0373
Practice Address - Country:US
Practice Address - Phone:304-643-4005
Practice Address - Fax:304-643-4007
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12375208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0050558000Medicaid
B42623Medicare UPIN
WV0050558000Medicaid