Healthcare Provider Details

I. General information

NPI: 1073572863
Provider Name (Legal Business Name): MARILYN L REGIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 HOLSONBACK DR
DAYTONA BEACH FL
32117-5114
US

IV. Provider business mailing address

PO BOX 9190
DAYTONA BEACH FL
32120-9190
US

V. Phone/Fax

Practice location:
  • Phone: 386-274-0790
  • Fax: 386-274-0800
Mailing address:
  • Phone: 386-274-0790
  • Fax: 386-274-0800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 24512
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: