=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689123382
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. MICHAEL JOSAPHAT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2016
-----------------------------------------------------
Last Update Date | 09/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2311 10TH AVE N SUITE 11
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-6605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-234-9203
-----------------------------------------------------
Fax | 561-469-6719
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2311 10TH AVE N SUITE 11
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-6605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-234-9203
-----------------------------------------------------
Fax | 561-469-6719
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247100000X
-----------------------------------------------------
Taxonomy Name | Radiologic Technologist
-----------------------------------------------------
License Number | CRT57773
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------