Healthcare Provider Details

I. General information

NPI: 1184684615
Provider Name (Legal Business Name): GERALD MARC JOSEPHSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13401 SUMMERLIN RD STE 8
FORT MYERS FL
33919-6593
US

IV. Provider business mailing address

5850 CENTRE AVE SUITE 800C
PITTSBURGH PA
15206-3780
US

V. Phone/Fax

Practice location:
  • Phone: 239-415-1880
  • Fax:
Mailing address:
  • Phone: 412-361-7300
  • Fax: 412-361-4857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS019130L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN7364
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: