Provider Demographics
NPI:1497893762
Name:BRAVOS, EMMANUEL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:DAVID
Last Name:BRAVOS
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 1:600 N WOLFE ST
Mailing Address - Street 2:NELSON 2-132
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287
Mailing Address - Country:US
Mailing Address - Phone:410-955-5608
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:NELSON 2 -132
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-5608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4906207L00000X
MDD67473207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD018295800Medicaid
MD132011YUWMedicare PIN
MD018295800Medicaid
MD132011YUXMedicare PIN