Basic Information
Provider Information | |||||||||
NPI: | 1962454082 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHALAL | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7593 BOYNTON BEACH BLVD | ||||||||
Address2: | SUITE 280 | ||||||||
City: | BOYNTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334376154 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5617335888 | ||||||||
FaxNumber: | 8887145190 | ||||||||
Practice Location | |||||||||
Address1: | 6056 BOYNTON BEACH BLVD STE 215 | ||||||||
Address2: |   | ||||||||
City: | BOYNTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334373500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5617335888 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2006 | ||||||||
LastUpdateDate: | 04/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME51490 | FL | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | P00443888 | 01 | FL | MEDICARE RAIL ROAD | OTHER | 04750 | 01 | FL | BCBS | OTHER | 4365337 | 01 | FL | AETNA | OTHER | 047076700 | 05 | FL |   | MEDICAID | 25639 | 01 | FL | NEIGHBORHOOD HEALTH | OTHER |