Provider Demographics
NPI:1881450401
Name:JOSEPH, GAETJENS TARDELLIE
Entity type:Individual
Prefix:
First Name:GAETJENS
Middle Name:TARDELLIE
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 45TH ST
Mailing Address - Street 2:
Mailing Address - City:MANGONIA PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2413
Mailing Address - Country:US
Mailing Address - Phone:561-844-6300
Mailing Address - Fax:
Practice Address - Street 1:901 45TH ST
Practice Address - Street 2:
Practice Address - City:MANGONIA PARK
Practice Address - State:FL
Practice Address - Zip Code:33407-2413
Practice Address - Country:US
Practice Address - Phone:561-844-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL.207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty