Provider Demographics
NPI:1952171704
Name:REGAN, JOSEPH STEPHEN
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:STEPHEN
Last Name:REGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15985 PRESERVE MARKETPLACE BLVD # 127
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-5509
Mailing Address - Country:US
Mailing Address - Phone:352-345-2926
Mailing Address - Fax:
Practice Address - Street 1:12020 SUNSHINE GROVE RD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34614-3429
Practice Address - Country:US
Practice Address - Phone:352-345-2926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLR25049766360172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver