Healthcare Provider Details

I. General information

NPI: 1144213828
Provider Name (Legal Business Name): MARY L OGRADY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 BAYOU BLVD #7
PENSACOLA FL
32503-2194
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-478-1104
  • Fax: 850-478-4289
Mailing address:
  • Phone: 904-450-6063
  • Fax: 904-539-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME87300
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: