Healthcare Provider Details

I. General information

NPI: 1972914174
Provider Name (Legal Business Name): SCOTT T MARBERRY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2014
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14810 OLD SAINT AUGUSTINE RD STE 101
JACKSONVILLE FL
32258-2558
US

IV. Provider business mailing address

705 WELLS RD STE 300
ORANGE PARK FL
32073-2982
US

V. Phone/Fax

Practice location:
  • Phone: 904-435-0600
  • Fax: 904-264-9750
Mailing address:
  • Phone: 904-282-6331
  • Fax: 904-619-1080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME126999
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME126999
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: