Provider Demographics
NPI:1366589780
Name:MARTA JACENYIK LLC
Entity type:Organization
Organization Name:MARTA JACENYIK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACENYIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-934-9866
Mailing Address - Street 1:PO BOX 1171
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32562-1171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3759 BENGAL RD
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-3454
Practice Address - Country:US
Practice Address - Phone:850-934-9866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67496207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBJ53792Medicare UPIN
FLK3333Medicare ID - Type Unspecified