1144296963 NPI number — DAVID EUGENE MARTIN MD PC

Table of content: (NPI 1144296963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144296963 NPI number — DAVID EUGENE MARTIN MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAVID EUGENE MARTIN MD PC
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:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144296963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 WOODCHASE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGRANGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30240-9734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-885-1349
Provider Business Mailing Address Fax Number:
706-845-3094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1514 VERNON RD
Provider Second Line Business Practice Location Address:
WEST GEORGIA HEALTH SYSTEM
Provider Business Practice Location Address City Name:
LAGRANGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30240-4131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-845-3175
Provider Business Practice Location Address Fax Number:
706-845-3094
Provider Enumeration Date:
02/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
706-845-3175

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300032215B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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