Healthcare Provider Details

I. General information

NPI: 1649749441
Provider Name (Legal Business Name): JOE SAMUEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13681 DOCTORS WAY
FORT MYERS FL
33912-4300
US

IV. Provider business mailing address

10034 RAVELLO BLVD
FORT MYERS FL
33905-5489
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-1000
  • Fax:
Mailing address:
  • Phone: 239-565-8395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberRPT75127
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9542234
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: