Provider Demographics
NPI:1760784268
Name:JOSEPH THEVENIN JR, MD PA
Entity Type:Organization
Organization Name:JOSEPH THEVENIN JR, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:THEVENIN JR, MD
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:305-238-8561
Mailing Address - Street 1:9635 SW 181 TERRACE
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-5630
Mailing Address - Country:US
Mailing Address - Phone:305-238-8561
Mailing Address - Fax:305-238-4089
Practice Address - Street 1:9635 SW 181 TERRACE
Practice Address - Street 2:PALMETTO BAY
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-5630
Practice Address - Country:US
Practice Address - Phone:305-238-8561
Practice Address - Fax:305-238-4089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059735001Medicaid
FL059735001Medicaid
FL14793Medicare PIN