Provider Demographics
NPI:1497758338
Name:JURICIC, MARILYN L (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:L
Last Name:JURICIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:800-480-5243
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:1400 N US HIGHWAY 441 STE 912
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-6811
Practice Address - Country:US
Practice Address - Phone:352-750-1277
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 71383207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31631OtherBLUE CROSS BLUE SHIELD
FL018050900Medicaid
FLP00224863OtherMEDICARD RAILROAD
FL3785224OtherAETNA
FL31631OtherBLUE CROSS BLUE SHIELD
FL31631OtherBLUE CROSS BLUE SHIELD
FLP00224863OtherMEDICARD RAILROAD