Provider Demographics
NPI:1508288101
Name:BROWN, JOSEPH
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:BROWN
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 1:2795 FORBES ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-7616
Mailing Address - Country:US
Mailing Address - Phone:904-387-6033
Mailing Address - Fax:904-387-6033
Practice Address - Street 1:2795 FORBES ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-7616
Practice Address - Country:US
Practice Address - Phone:904-387-6033
Practice Address - Fax:904-387-6033
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJB117817171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686038900Medicaid