Provider Demographics
NPI:1356630826
Name:JOSEPH M. MAVICA.D.O. PA
Entity Type:Organization
Organization Name:JOSEPH M. MAVICA.D.O. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:B
Authorized Official - Last Name:MAVICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-395-3778
Mailing Address - Street 1:2600 N MILITARY TRL
Mailing Address - Street 2:SUITE 215
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6312
Mailing Address - Country:US
Mailing Address - Phone:561-395-3778
Mailing Address - Fax:561-395-5691
Practice Address - Street 1:2600 N MILITARY TRL
Practice Address - Street 2:SUITE 215
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6312
Practice Address - Country:US
Practice Address - Phone:561-395-3778
Practice Address - Fax:561-395-5691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS00063802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG03279Medicare UPIN