Provider Demographics
NPI:1841286036
Name:BRAVO, KEITH MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:MICHAEL
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 2581
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-1781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 COLLIERS WAY
Practice Address - Street 2:SUITE 502
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5053
Practice Address - Country:US
Practice Address - Phone:304-723-4328
Practice Address - Fax:304-723-5814
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19983207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2147582Medicaid
WV6000332000Medicaid
G97809Medicare UPIN
OH2147582Medicaid