Basic Information
| Provider Information | |||||||||
| NPI: | 1962491167 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NINKE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | ALBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300467694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783123294 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1324 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636871321 | ||||||||
| FaxNumber: | 8632841730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0007X | 84424 | GA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck | 207YX0007X | ME85949 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck | 207Y00000X | ME85949 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1962491167 | 01 | FL | NPI | OTHER |