1114312261 NPI number — DR. BENYAM PETROS YOSEPH M.D.

Table of content: DR. BENYAM PETROS YOSEPH M.D. (NPI 1114312261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114312261 NPI number — DR. BENYAM PETROS YOSEPH M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOSEPH
Provider First Name:
BENYAM
Provider Middle Name:
PETROS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YOSEPH
Provider Other First Name:
BEN
Provider Other Middle Name:
PETROS
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D. PH.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1114312261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1508 SOFTSHELL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34771-7516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-245-4392
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HOME PHYSICIANS GROUP
Provider Second Line Business Practice Location Address:
7620 LAKE UNDERHILL RD
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32822-3282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-235-0692
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 137448 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 104489800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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