Provider Demographics
NPI:1790096170
Name:BRAVATA, KURT RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:RUSSELL
Last Name:BRAVATA
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 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-328-6501
Mailing Address - Fax:417-328-6338
Practice Address - Street 1:201 S ASH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MO
Practice Address - Zip Code:65622-8674
Practice Address - Country:US
Practice Address - Phone:417-345-6100
Practice Address - Fax:417-345-6866
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013030074208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01259379OtherPALMETTO GBA RAILROAD
MOP01259379OtherPALMETTO GBA RAILROAD