Provider Demographics
NPI:1588790018
Name:BRAVO, MELANIE A
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:A
Last Name:BRAVO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5218
Mailing Address - Country:US
Mailing Address - Phone:718-209-1006
Mailing Address - Fax:718-209-0510
Practice Address - Street 1:1650 E 91ST ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5218
Practice Address - Country:US
Practice Address - Phone:718-209-1006
Practice Address - Fax:718-209-0510
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1366112080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00352552Medicaid