Provider Demographics
NPI:1598726853
Name:BRAVO, JORGE JOSE II (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:JOSE
Last Name:BRAVO
Suffix:II
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:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-1449
Mailing Address - Country:US
Mailing Address - Phone:985-446-8994
Mailing Address - Fax:985-447-8385
Practice Address - Street 1:602 N ACADIA RD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4847
Practice Address - Country:US
Practice Address - Phone:985-493-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.011992207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1300381Medicaid
LAB62476Medicare UPIN
LA50555Medicare ID - Type Unspecified