Healthcare Provider Details

I. General information

NPI: 1336602804
Provider Name (Legal Business Name): JOEL JOHN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20900 BISCAYNE BLVD
AVENTURA FL
33180-1407
US

IV. Provider business mailing address

145 SW 13TH ST
MIAMI FL
33130-4226
US

V. Phone/Fax

Practice location:
  • Phone: 305-682-7000
  • Fax:
Mailing address:
  • Phone: 813-767-1635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS17762
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS17762
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: