Healthcare Provider Details

I. General information

NPI: 1366858672
Provider Name (Legal Business Name): MARY CROSS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6002 BERRYHILL RD
MILTON FL
32570-5062
US

IV. Provider business mailing address

6002 BERRYHILL RD
MILTON FL
32570-5062
US

V. Phone/Fax

Practice location:
  • Phone: 706-575-4800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberUO3905
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS14786
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: