Provider Demographics
NPI:1881001972
Name:JOSEPH, PROSPER (MD)
Entity Type:Individual
Prefix:
First Name:PROSPER
Middle Name:
Last Name:JOSEPH
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 1:1774 15TH AVE N
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-1734
Mailing Address - Country:US
Mailing Address - Phone:407-965-9329
Mailing Address - Fax:786-272-0476
Practice Address - Street 1:1774 15TH AVE N
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-1734
Practice Address - Country:US
Practice Address - Phone:407-965-9329
Practice Address - Fax:786-272-0476
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRPHT3903183700000X
FL2343212103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No183700000XPharmacy Service ProvidersPharmacy Technician