Provider Demographics
NPI:1073834404
Name:MARTIN, ROBERT AMBROSE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:AMBROSE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2745
Mailing Address - Country:US
Mailing Address - Phone:706-882-8831
Mailing Address - Fax:706-298-4989
Practice Address - Street 1:380 S DAVIS RD
Practice Address - Street 2:SUITE E&F
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-2588
Practice Address - Country:US
Practice Address - Phone:706-882-8831
Practice Address - Fax:706-298-4989
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC32892207Q00000X
GA071595207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine