1710152731 NPI number — MR. JOSEPH F. REAGAN OT

Table of content: MR. JOSEPH F. REAGAN OT (NPI 1710152731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710152731 NPI number — MR. JOSEPH F. REAGAN OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
REAGAN
Provider First Name:
JOSEPH
Provider Middle Name:
F.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710152731
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1153 GULF BREEZE PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULF BREEZE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32561-4835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-932-6382
Provider Business Mailing Address Fax Number:
850-932-9215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5827 HIGHWAY 90
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32583-1763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-983-8583
Provider Business Practice Location Address Fax Number:
850-983-8973
Provider Enumeration Date:
04/30/2008

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: 225X00000X , with the licence number:  OT5911 , 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)