Healthcare Provider Details

I. General information

NPI: 1649246455
Provider Name (Legal Business Name): JOSEPH JAMES DAVERSA JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12368 SW 82ND AVE
MIAMI FL
33156-5223
US

IV. Provider business mailing address

12368 SW 82ND AVE
MIAMI FL
33156-5223
US

V. Phone/Fax

Practice location:
  • Phone: 305-253-4218
  • Fax: 305-233-5844
Mailing address:
  • Phone: 305-253-4218
  • Fax: 305-233-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME 0014994
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME 0014994
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: