Basic Information
| Provider Information | |||||||||
| NPI: | 1972914174 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARBERRY | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 WELLS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320732982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042826331 | ||||||||
| FaxNumber: | 9046191080 | ||||||||
| Practice Location | |||||||||
| Address1: | 14810 OLD SAINT AUGUSTINE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322582558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044350600 | ||||||||
| FaxNumber: | 9042649750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2014 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | ME126999 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | ME126999 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 019878900 | 05 | FL | MEDICAID |