Provider Demographics
NPI:1245262104
Name:BRAVO, FERNANDO B (MD)
Entity type:Individual
Prefix:
First Name:FERNANDO
Middle Name:B
Last Name: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:PO BOX 20207
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93390-0207
Mailing Address - Country:US
Mailing Address - Phone:661-327-4712
Mailing Address - Fax:661-327-4004
Practice Address - Street 1:3110 LATTE LANE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93312-2141
Practice Address - Country:US
Practice Address - Phone:661-327-4712
Practice Address - Fax:661-327-4004
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72360174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00358772OtherRAILROAD MEDICARE
CA00A723600Medicaid
CAA72360OtherCA LICENSE
CAH51674Medicare UPIN
CA00A723600Medicaid