Provider Demographics
NPI:1114169570
Name:MARTIN, THOMAS DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:DAVID
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 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 WEALTHY ST SE
Practice Address - Street 2:SUITE 180
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2969
Practice Address - Country:US
Practice Address - Phone:616-774-8501
Practice Address - Fax:616-774-8595
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094619208600000X
NC2014-00116208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1114169570Medicaid
NC2014-00116OtherNC LICENSE
SCNC2153Medicaid
NCNCJ403BMedicare PIN
NCNCJ403AMedicare PIN