Provider Demographics
NPI:1609076058
Name:BRATVOLD, JARED MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:MICHAEL
Last Name:BRATVOLD
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:PO BOX 405827
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6025 WALNUT GROVE ROAD
Practice Address - Street 2:SUITE 400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-227-9882
Practice Address - Fax:901-227-9883
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48907208600000X, 208600000X
TXBP1-0025010208600000X
TXP0171208600000X
MNR134904-5208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery