Basic Information
| Provider Information | |||||||||
| NPI: | 1336301753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEFAN ACTA | ||||||||
| FirstName: | MARNIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 NW 64TH TER | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523313583 | ||||||||
| FaxNumber: | 3523313669 | ||||||||
| Practice Location | |||||||||
| Address1: | 1121 NW 64TH TER | ||||||||
| Address2: | SUITE A | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523313583 | ||||||||
| FaxNumber: | 3523313669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | TRN-12713 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | ME113204 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 005575900 | 05 | FL | MEDICAID |