Provider Demographics
NPI: | 1851798078 |
---|---|
Name: | D GLEN JOSEPH PLLC |
Entity Type: | Organization |
Organization Name: | D GLEN JOSEPH PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | DARRYL |
Authorized Official - Middle Name: | GLEN |
Authorized Official - Last Name: | JOSEPH |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | OD |
Authorized Official - Phone: | 561-715-2737 |
Mailing Address - Street 1: | 21533 HALSTEAD DR |
Mailing Address - Street 2: | |
Mailing Address - City: | BOCA RATON |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33428-4844 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 561-715-2737 |
Mailing Address - Fax: | 954-431-0745 |
Practice Address - Street 1: | 12055 PINES BLVD |
Practice Address - Street 2: | |
Practice Address - City: | PEMBROKE PINES |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33026-4112 |
Practice Address - Country: | US |
Practice Address - Phone: | 954-638-3139 |
Practice Address - Fax: | 954-431-0745 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-12-03 |
Last Update Date: | 2014-12-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | OPC 3971 | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Single Specialty |