Provider Demographics
NPI:1265419345
Name:JOSEPH, MARY V (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:V
Last Name:JOSEPH
Suffix:
Gender:F
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:PO BOX 616788
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32861-6788
Mailing Address - Country:US
Mailing Address - Phone:407-290-0555
Mailing Address - Fax:407-295-0028
Practice Address - Street 1:6320 OLD WINTER GARDEN RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-1381
Practice Address - Country:US
Practice Address - Phone:407-290-0555
Practice Address - Fax:407-295-0028
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL374676300Medicaid
FL23656UMedicare PIN
FL374676300Medicaid