Provider Demographics
NPI:1619991148
Name:FERNANDEZ BRAVO, ALBERTO O (MD)
Entity Type:Individual
Prefix:
First Name:ALBERTO
Middle Name:O
Last Name:FERNANDEZ 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 1:780 CANTON RD NE STE 328
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7289
Mailing Address - Country:US
Mailing Address - Phone:470-267-1760
Mailing Address - Fax:470-986-7002
Practice Address - Street 1:780 CANTON RD NE STE 328
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7289
Practice Address - Country:US
Practice Address - Phone:470-267-1760
Practice Address - Fax:470-986-7002
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD192944207RG0100X
LAMD.10541R207RG0100X
FLME0058947207RG0100X
GA93541207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14082YMedicare PIN
FLF04151Medicare UPIN
FL14082WMedicare PIN