Provider Demographics
NPI:1689123382
Name:JOSAPHAT, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:JOSAPHAT
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 1:2311 10TH AVE N
Mailing Address - Street 2:SUITE 11
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6605
Mailing Address - Country:US
Mailing Address - Phone:954-234-9203
Mailing Address - Fax:561-469-6719
Practice Address - Street 1:2311 10TH AVE N
Practice Address - Street 2:SUITE 11
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-6605
Practice Address - Country:US
Practice Address - Phone:954-234-9203
Practice Address - Fax:561-469-6719
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCRT57773247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC10329OtherAHCA