Provider Demographics
NPI:1184165623
Name:PRADO BRABATA, JORGE MANUEL
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:MANUEL
Last Name:PRADO BRABATA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 COLLEEN DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-4607
Mailing Address - Country:US
Mailing Address - Phone:408-887-1263
Mailing Address - Fax:
Practice Address - Street 1:290 IOOF AVE
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-5204
Practice Address - Country:US
Practice Address - Phone:408-846-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator