1053110619 NPI number — MAGNOLIA MEDICAL CLINIC P.A.

Table of content: MRS. LIDIA MARIE DOBRONOS R.PH. (NPI 1780693937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053110619 NPI number — MAGNOLIA MEDICAL CLINIC P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAGNOLIA MEDICAL CLINIC P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
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NPI Number Information

NPI Number:
1053110619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
319 GREEN ACRES RD STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WALTON BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32547-1170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4012 COMMONS DR W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DESTIN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32541-8422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-243-7681
Provider Business Practice Location Address Fax Number:
850-243-0471
Provider Enumeration Date:
03/07/2025

Additional Information

Authorized Official

Authorized Official Last Name:
WEATHERINGTON
Authorized Official First Name:
CRYSTAL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
850-243-0520

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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