Provider Demographics
NPI:1558470443
Name:BRAVO, JUAN OSCAR (MD, CWS)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:OSCAR
Last Name:BRAVO
Suffix:
Gender:M
Credentials:MD, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 FITZGERALD RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2633
Mailing Address - Country:US
Mailing Address - Phone:863-777-2736
Mailing Address - Fax:863-777-2724
Practice Address - Street 1:170 FITZGERALD RD STE 1
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2633
Practice Address - Country:US
Practice Address - Phone:863-777-2736
Practice Address - Fax:863-777-2724
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74194207NS0135X, 2083P0011X
FLME-74194207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271611900Medicaid
FL44573OtherBCBS
FL271611900Medicaid
FL44573OtherBCBS