Provider Demographics
NPI:1346340254
Name:INNOCENT, MARILYN B (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:B
Last Name:INNOCENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARILYN
Other - Middle Name:BELIZAIRE
Other - Last Name:INNOCENT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 221313
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33422-1313
Mailing Address - Country:US
Mailing Address - Phone:561-429-5086
Mailing Address - Fax:561-290-4144
Practice Address - Street 1:220 S DIXIE HWY
Practice Address - Street 2:SUITE 4
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-4153
Practice Address - Country:US
Practice Address - Phone:561-429-5086
Practice Address - Fax:561-290-4144
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93404207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007403900Medicaid
FLGJ714YMedicare PIN
FL007403900Medicaid