Provider Demographics
NPI:1114977493
Name:MARTI, CHARLES JAY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JAY
Last Name:MARTI
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 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:600 N PICKAWAY ST
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-2409
Practice Address - Country:US
Practice Address - Phone:740-474-2126
Practice Address - Fax:740-477-1022
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053086207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0615383Medicaid
000000317196OtherBCBS CIRCLEVILLE
P00111888OtherRAILROAD MEDICARE
000000326800OtherBCBS
OH0615383Medicaid
OHMA0872846Medicare PIN
P00111888OtherRAILROAD MEDICARE