Healthcare Provider Details

I. General information

NPI: 1962491167
Provider Name (Legal Business Name): JOSEPH ALBERT NINKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

IV. Provider business mailing address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1321
  • Fax: 863-284-1730
Mailing address:
  • Phone: 678-312-3294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number84424
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberME85949
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME85949
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: