Provider Demographics
NPI:1508861808
Name:BRAVO, MANUEL EDUARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:EDUARDO
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 1:19201 MONTGOMERY VILLAGE AVE
Mailing Address - Street 2:STE A12
Mailing Address - City:MONTGOMRY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-5057
Mailing Address - Country:US
Mailing Address - Phone:301-670-0070
Mailing Address - Fax:301-977-4916
Practice Address - Street 1:19201 MONTGOMERY VILLAGE AVE
Practice Address - Street 2:STE A12
Practice Address - City:MONTGOMRY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-5057
Practice Address - Country:US
Practice Address - Phone:301-670-0070
Practice Address - Fax:301-977-4916
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-08-07
Provider Licenses
StateLicense IDTaxonomies
MDD09284208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics