Provider Demographics
NPI:1740272376
Name:BRAVERMAN, STUART J (MD)
Entity type:Individual
Prefix:
First Name:STUART
Middle Name:J
Last Name:BRAVERMAN
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 1:3300 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2111
Mailing Address - Country:US
Mailing Address - Phone:660-827-0423
Mailing Address - Fax:660-827-5510
Practice Address - Street 1:3300 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2111
Practice Address - Country:US
Practice Address - Phone:660-827-0423
Practice Address - Fax:660-827-5510
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100311208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO020036256OtherRR MEDICARE
MO203303201Medicaid
MOC181484Medicare PIN