Provider Demographics
NPI:1710479373
Name:TA, JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:TA
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 1:1435 AMANDA PARK LN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-8651
Mailing Address - Country:US
Mailing Address - Phone:304-881-4263
Mailing Address - Fax:
Practice Address - Street 1:96 JONATHAN LUCAS ST
Practice Address - Street 2:SUITE 301 CSB MSC 606
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8900
Practice Address - Country:US
Practice Address - Phone:843-792-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL523472084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology