Provider Demographics
NPI:1205246378
Name:DRAVIAM, KATHERINE BAUTISTA (DO)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:BAUTISTA
Last Name:DRAVIAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-5271
Mailing Address - Country:US
Mailing Address - Phone:407-518-1074
Mailing Address - Fax:
Practice Address - Street 1:391 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5271
Practice Address - Country:US
Practice Address - Phone:407-518-1074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS15083207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL025080600Medicaid