Provider Demographics
NPI:1144231671
Name:JOSEPHSON, GARY D (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:D
Last Name:JOSEPHSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-7474
Mailing Address - Fax:239-343-4190
Practice Address - Street 1:16410 HEALTHPARK COMMONS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-9621
Practice Address - Country:US
Practice Address - Phone:239-343-7474
Practice Address - Fax:239-343-4190
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73739207Y00000X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252814201Medicaid
GA000870504AMedicaid
FL252814201Medicaid
GA000870504AMedicaid