Provider Demographics
NPI:1093153405
Name:MARTIN, MELISSA ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ROSE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3401 CIVIC CENTER BLVD
Mailing Address - Street 2:9NW63
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4319
Mailing Address - Country:US
Mailing Address - Phone:215-590-1220
Mailing Address - Fax:215-590-2768
Practice Address - Street 1:1700 S BROAD ST
Practice Address - Street 2:SUITE #301
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2315
Practice Address - Country:US
Practice Address - Phone:215-467-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT203779208000000X
PAMD457832208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics