1104520402 NPI number — GREDYMAR PATRICIA MARIN TOVAR MD

Table of content: GREDYMAR PATRICIA MARIN TOVAR MD (NPI 1104520402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104520402 NPI number — GREDYMAR PATRICIA MARIN TOVAR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARIN TOVAR
Provider First Name:
GREDYMAR
Provider Middle Name:
PATRICIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104520402
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 746638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-6638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-202-2092
Provider Business Mailing Address Fax Number:
904-376-4075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11851 STILLWOOD PINES BLVD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32224-4435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-376-4935
Provider Business Practice Location Address Fax Number:
904-376-3218
Provider Enumeration Date:
03/29/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME181900 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 15053 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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