Provider Demographics
NPI:1154716603
Name:JOSEPH, SHANE (DO)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W KALEY ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2970
Mailing Address - Country:US
Mailing Address - Phone:407-423-2581
Mailing Address - Fax:407-849-6470
Practice Address - Street 1:500 N HIATUS RD STE 200
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-5213
Practice Address - Country:US
Practice Address - Phone:954-437-4800
Practice Address - Fax:954-437-6628
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
RIDO010112085R0202X
FLOS175072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program