Provider Demographics
NPI:1326479056
Name:JOSEPH SACKETT, M.D.
Entity Type:Organization
Organization Name:JOSEPH SACKETT, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:FREDERIC
Authorized Official - Last Name:SACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-280-4388
Mailing Address - Street 1:611 PONTE VEDRA BLVD
Mailing Address - Street 2:UNIT 122
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-4730
Mailing Address - Country:US
Mailing Address - Phone:904-280-4388
Mailing Address - Fax:904-280-0807
Practice Address - Street 1:611 PONTE VEDRA BLVD
Practice Address - Street 2:UNIT 122
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-4730
Practice Address - Country:US
Practice Address - Phone:904-280-4388
Practice Address - Fax:904-280-0807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18916-20261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology