Provider Demographics
NPI:1144213828
Name:OGRADY, MARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:OGRADY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:5190 BAYOU BLVD
Practice Address - Street 2:#7
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2194
Practice Address - Country:US
Practice Address - Phone:850-478-1104
Practice Address - Fax:850-478-4289
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
29221OtherBCBS
FLC333OtherHEALTH 1ST NETWORK
FL267193000Medicaid