Provider Demographics
NPI:1952377764
Name:JOSEPH J DAVERSA JR MD PA
Entity Type:Organization
Organization Name:JOSEPH J DAVERSA JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DAVERSA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:305-253-4218
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 00149942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049162400Medicaid
FLEF832AMedicare PIN
FL049162400Medicaid