Provider Demographics
NPI:1114076593
Name:MARTIN, M NICHOLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:M
Middle Name:NICHOLAS
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MARVIN
Other - Middle Name:N
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4925 ROCKWELL RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-8509
Mailing Address - Country:US
Mailing Address - Phone:859-744-1061
Mailing Address - Fax:859-744-1062
Practice Address - Street 1:4925 ROCKWELL RD
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-8509
Practice Address - Country:US
Practice Address - Phone:859-744-1061
Practice Address - Fax:859-744-1062
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17782207Q00000X, 207QB0002X
IN24668207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000045743OtherANTHEM
KY64177827OtherUNISYS
610882170OtherVARIABLE TAX ID
KY065909137Medicaid
5910070OtherAETNA
80031821OtherMEDICAARE PALMETTO GBA
80031821OtherMEDICAARE PALMETTO GBA
C78414Medicare UPIN