Provider Demographics
NPI:1174145304
Name:BACON, MARJORIE DINA (MD)
Entity type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:DINA
Last Name:BACON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:442 PASEO REYES DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8558
Mailing Address - Country:US
Mailing Address - Phone:904-544-1738
Mailing Address - Fax:904-872-8863
Practice Address - Street 1:442 PASEO REYES DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8558
Practice Address - Country:US
Practice Address - Phone:904-544-1738
Practice Address - Fax:904-872-8863
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA338808207Q00000X
AZ1908R77909207Q00000X
FLME158234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine