Provider Demographics
NPI:1144499336
Name:JOHN BRAVO DACANAY MD PC
Entity type:Organization
Organization Name:JOHN BRAVO DACANAY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:DACANAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-474-9744
Mailing Address - Street 1:120 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-5618
Mailing Address - Country:US
Mailing Address - Phone:928-474-9744
Mailing Address - Fax:
Practice Address - Street 1:120 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-5618
Practice Address - Country:US
Practice Address - Phone:928-474-9744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37784207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicaid
AZPENDINGMedicaid