Provider Demographics
NPI:1699024075
Name:SO, JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:SO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-2460
Mailing Address - Country:US
Mailing Address - Phone:215-983-0635
Mailing Address - Fax:
Practice Address - Street 1:169 W CHEW AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-2454
Practice Address - Country:US
Practice Address - Phone:215-983-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT022052174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist