Provider Demographics
NPI:1588288203
Name:JOSEPH, SAMUEL (PA-C, MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:PA-C, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22730 SW 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-6258
Mailing Address - Country:US
Mailing Address - Phone:561-573-8521
Mailing Address - Fax:
Practice Address - Street 1:4601 N HIGHWAY 19A
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2039
Practice Address - Country:US
Practice Address - Phone:352-602-7924
Practice Address - Fax:754-206-2394
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHSE32842207Q00000X
IL238000625208600000X
PRTPPA373208D00000X
FLTPPA373363A00000X
AZ9733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice