Provider Demographics
NPI:1598739823
Name:BRAVO, JULIO RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:JULIO
Middle Name:RAFAEL
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 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-713-0947
Mailing Address - Fax:
Practice Address - Street 1:312 JONESTOWN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4621
Practice Address - Country:US
Practice Address - Phone:336-716-7576
Practice Address - Fax:336-702-9342
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22552174400000X
GA92445207RR0500X
NC36657207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1598739823Medicaid
GA202G701531OtherMEDICARE ID
NC5907255Medicaid
LA1987158Medicaid
NCP00479037OtherRAILROAD MEDICARE
VA1598739823Medicaid
NCP00479037OtherRAILROAD MEDICARE