Provider Demographics
NPI:1649223470
Name:JOSEPHSON, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:JOSEPHSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26067
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84126-0067
Mailing Address - Country:US
Mailing Address - Phone:239-624-0400
Mailing Address - Fax:239-624-0401
Practice Address - Street 1:311 9TH ST N STE 306
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5878
Practice Address - Country:US
Practice Address - Phone:239-624-0340
Practice Address - Fax:239-624-0341
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87490207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78735OtherBCBS
FL009365200Medicaid
FL78735WOtherMEDICARE
FL78735OtherBCBS
FL78735VMedicare PIN