Provider Demographics
NPI:1124005814
Name:MARTIN, ALVIN W (MD)
Entity Type:Individual
Prefix:
First Name:ALVIN
Middle Name:W
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:PO BOX 950251
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0251
Mailing Address - Country:US
Mailing Address - Phone:502-897-9594
Mailing Address - Fax:502-736-4456
Practice Address - Street 1:2307 GREENE WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-4009
Practice Address - Country:US
Practice Address - Phone:502-897-9594
Practice Address - Fax:502-736-4456
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22866207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64228661Medicaid
KY000000596219OtherANTHEM-BLUE CROSS-BLUE SHIELD
KY3691838000OtherPASSPORT ADVANTAGE
KY50021837OtherPASSPORT HEALTH PLAN
IN200071070Medicaid
KY64228661Medicaid
KY0075427Medicare PIN