Provider Demographics
NPI:1083049837
Name:JOSEPH, LARRY BENARD
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:BENARD
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 FLATBUSH AVENUE #152
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216
Mailing Address - Country:US
Mailing Address - Phone:646-244-2091
Mailing Address - Fax:
Practice Address - Street 1:237 FLATBUSH AVE # 152
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-5224
Practice Address - Country:US
Practice Address - Phone:646-244-2091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY620377174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist