Provider Demographics
NPI:1336258243
Name:JUAN O BRAVO MD PL
Entity Type:Organization
Organization Name:JUAN O BRAVO MD PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:MD, CWS
Authorized Official - Phone:863-398-8362
Mailing Address - Street 1:170 FITZGERALD RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2633
Mailing Address - Country:US
Mailing Address - Phone:863-777-2736
Mailing Address - Fax:863-777-2724
Practice Address - Street 1:3000 CORAL HILLS DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4108
Practice Address - Country:US
Practice Address - Phone:863-398-8362
Practice Address - Fax:813-754-7565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271611900Medicaid
FLK9451Medicare ID - Type Unspecified
FL271611900Medicaid