Healthcare Provider Details

I. General information

NPI: 1992336721
Provider Name (Legal Business Name): JOSH IMMITT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19531 COCHRAN BLVD
PORT CHARLOTTE FL
33948-2081
US

IV. Provider business mailing address

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 941-255-3535
  • Fax: 941-766-7999
Mailing address:
  • Phone: 778-563-7748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: