Provider Demographics
NPI:1144381450
Name:RAYBURN, MARTIN T JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:T
Last Name:RAYBURN
Suffix:JR
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 1:1411 HATCHER LANE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401
Mailing Address - Country:US
Mailing Address - Phone:931-381-1499
Mailing Address - Fax:931-381-1499
Practice Address - Street 1:1411 HATCHER LANE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401
Practice Address - Country:US
Practice Address - Phone:931-381-1499
Practice Address - Fax:931-381-1499
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD3322207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2003455OtherBLUE CROSS
TN070016615OtherMEDICARE RAILROAD
TN3118674Medicaid
TN3118674Medicare ID - Type Unspecified
TN3118674Medicaid