Provider Demographics
NPI:1265608616
Name:FANFAN, JOSEPH JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:FANFAN
Suffix:JR
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 1:2630N ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-2550
Mailing Address - Country:US
Mailing Address - Phone:954-525-4900
Mailing Address - Fax:954-396-3110
Practice Address - Street 1:2630N ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33311-2550
Practice Address - Country:US
Practice Address - Phone:954-525-4900
Practice Address - Fax:954-396-3110
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068166100Medicaid
FL068166100Medicaid