Healthcare Provider Details

I. General information

NPI: 1174145304
Provider Name (Legal Business Name): MARJORIE DINA BACON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 PASEO REYES DR
ST AUGUSTINE FL
32095-8558
US

IV. Provider business mailing address

442 PASEO REYES DR
ST AUGUSTINE FL
32095-8558
US

V. Phone/Fax

Practice location:
  • Phone: 904-544-1738
  • Fax: 904-872-8863
Mailing address:
  • Phone: 904-544-1738
  • Fax: 904-872-8863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number338808
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1908R77909
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME158234
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: