Basic Information
| Provider Information | |||||||||
| NPI: | 1295182731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOSEPH | ||||||||
| FirstName: | JEEVAN | ||||||||
| MiddleName: | PAULY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9400 TURKEY LAKE RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328198001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218435500 | ||||||||
| FaxNumber: | 3218435550 | ||||||||
| Practice Location | |||||||||
| Address1: | 334 THOMAS MORE PKWY | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410173464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593410288 | ||||||||
| FaxNumber: | 8593417482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2016 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME139375 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | 272961 | MA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 55956 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.