Provider Demographics
NPI:1861492829
Name:BARNETT, MARJORIE LEE (MD MBA)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:LEE
Last Name:BARNETT
Suffix:
Gender:F
Credentials:MD MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 1ST ST N
Mailing Address - Street 2:APT 305
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-8403
Mailing Address - Country:US
Mailing Address - Phone:845-701-6677
Mailing Address - Fax:
Practice Address - Street 1:449 WEST 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405
Practice Address - Country:US
Practice Address - Phone:850-769-8341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155839208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02654391Medicaid
NY02654391Medicaid
E56385Medicare UPIN