Provider Demographics
NPI:1083111207
Name:MARTUCCI, JOHN ANDREW (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:MARTUCCI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 RIVERSTONE TER STE 101
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-1703
Mailing Address - Country:US
Mailing Address - Phone:678-336-8234
Mailing Address - Fax:
Practice Address - Street 1:132 RIVERSTONE TER STE 101
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-1703
Practice Address - Country:US
Practice Address - Phone:330-629-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.004003213ES0103X
GAPOD001519213ES0103X
MA1484213ES0103X
PASC007153213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery