Provider Demographics
NPI:1194162958
Name:BRAVIN, DANIEL ALLEN (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:ALLEN
Last Name:BRAVIN
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 1:1001 E PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5155
Mailing Address - Country:US
Mailing Address - Phone:417-875-3462
Mailing Address - Fax:
Practice Address - Street 1:3800 S NATIONAL AVE STE 600
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807
Practice Address - Country:US
Practice Address - Phone:417-875-3846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019026844207X00000X, 207XX0801X
CAA153736207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200072314Medicaid