Provider Demographics
NPI:1649246455
Name:DAVERSA, JOSEPH JAMES JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JAMES
Last Name:DAVERSA
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 1:12368 SW 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5223
Mailing Address - Country:US
Mailing Address - Phone:305-253-4218
Mailing Address - Fax:305-233-5844
Practice Address - Street 1:12368 SW 82ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-5223
Practice Address - Country:US
Practice Address - Phone:305-253-4218
Practice Address - Fax:305-233-5844
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 00149942084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049162400Medicaid
FLD86486Medicare UPIN
FLEF832AMedicare PIN