1356151724 NPI number — BRAVO WELLCARE NETWORK, LLC

Table of content: MICHAEL EUGENE JOHNSON MD (NPI 1437174000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356151724 NPI number — BRAVO WELLCARE NETWORK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRAVO WELLCARE NETWORK, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356151724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7950 NW 53RD STREET
Provider Second Line Business Mailing Address:
SUITE 337 #1007
Provider Business Mailing Address City Name:
DORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33166
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-988-1936
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7950 NW 53RD STREET
Provider Second Line Business Practice Location Address:
SUITE 337 #1007
Provider Business Practice Location Address City Name:
DORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-988-1936
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2025

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BRAVO MATOS
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
305-988-1936

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)