Healthcare Provider Details

I. General information

NPI: 1881001972
Provider Name (Legal Business Name): PROSPER JOSEPH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1774 15TH AVE N
LAKE WORTH FL
33460-1734
US

IV. Provider business mailing address

1774 15TH AVE N
LAKE WORTH FL
33460-1734
US

V. Phone/Fax

Practice location:
  • Phone: 407-965-9329
  • Fax: 786-272-0476
Mailing address:
  • Phone: 407-965-9329
  • Fax: 786-272-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberRPHT3903
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number2343212
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: