Provider Demographics
NPI:1528012044
Name:BRAVO, VICTOR L (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:L
Last Name:BRAVO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1215 S COULTER ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1758
Mailing Address - Country:US
Mailing Address - Phone:806-359-4701
Mailing Address - Fax:806-353-0091
Practice Address - Street 1:1215 S COULTER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1758
Practice Address - Country:US
Practice Address - Phone:806-359-4701
Practice Address - Fax:806-353-0091
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-11-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXH2258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4396376OtherAETNA
TX83110KOtherBCBS
TX83110KMedicare PIN
C13725Medicare UPIN