Provider Demographics
NPI:1205970134
Name:INNOCENT-SIMON, JOELLE M (DO)
Entity type:Individual
Prefix:MRS
First Name:JOELLE
Middle Name:M
Last Name:INNOCENT-SIMON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 S WATER ST
Mailing Address - Street 2:
Mailing Address - City:STARKE
Mailing Address - State:FL
Mailing Address - Zip Code:32091-4511
Mailing Address - Country:US
Mailing Address - Phone:904-368-2489
Mailing Address - Fax:904-368-2493
Practice Address - Street 1:1550 S WATER ST
Practice Address - Street 2:
Practice Address - City:STARKE
Practice Address - State:FL
Practice Address - Zip Code:32091-4511
Practice Address - Country:US
Practice Address - Phone:904-368-2489
Practice Address - Fax:904-368-2493
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0006902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1457448284OtherSHANDS STARKE MEDICAL GROUP
FL1942270905OtherNPI FOR GROUP
FL57355OtherBCBS
FL250170800Medicaid
FL1942270905OtherNPI FOR GROUP
FL1942270905OtherNPI FOR GROUP
FL57355OtherBCBS