Provider Demographics
NPI:1649557695
Name:BRAVERMAN REPORDUCTIVE IMMUNOLOGY
Entity Type:Organization
Organization Name:BRAVERMAN REPORDUCTIVE IMMUNOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-584-8710
Mailing Address - Street 1:135 PINELAWN RD STE 115
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3198
Mailing Address - Country:US
Mailing Address - Phone:516-584-8710
Mailing Address - Fax:516-584-8711
Practice Address - Street 1:155 E 76TH ST STE 1H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2810
Practice Address - Country:US
Practice Address - Phone:516-584-8710
Practice Address - Fax:516-584-8711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X
NY158551207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Multi-Specialty
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA06152700OtherNJ STATE LICENSE
NY195356OtherNY MEDICAL LICENSE