Healthcare Provider Details

I. General information

NPI: 1598717761
Provider Name (Legal Business Name): MARLENE S GOODFRIEND MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 N JEFFERSON ST
JACKSONVILLE FL
32209-6810
US

IV. Provider business mailing address

515 W 6TH ST MC #24
JACKSONVILLE FL
32206-4324
US

V. Phone/Fax

Practice location:
  • Phone: 904-359-3842
  • Fax: 904-359-3847
Mailing address:
  • Phone: 904-665-2410
  • Fax: 904-630-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME87093
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: