Provider Demographics
NPI:1497433221
Name:JOSEPH, MOISE
Entity Type:Individual
Prefix:
First Name:MOISE
Middle Name:
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 1:5108 ACOMA AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7970
Mailing Address - Country:US
Mailing Address - Phone:804-347-5052
Mailing Address - Fax:
Practice Address - Street 1:20200 W DIXIE HWY STE 902
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1926
Practice Address - Country:US
Practice Address - Phone:804-347-5052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJ210-540-81-296-0172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver