Provider Demographics
NPI:1164417713
Name:MARTIN, FREDERICK A (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:A
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 1:1958 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1940
Mailing Address - Country:US
Mailing Address - Phone:423-574-7575
Mailing Address - Fax:423-574-7576
Practice Address - Street 1:1958 W STATE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1940
Practice Address - Country:US
Practice Address - Phone:423-574-7575
Practice Address - Fax:423-574-7576
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD35685207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010178835Medicaid
TN4107515OtherBCBS TN
TN62172092012OtherJOHN DEERE #
TN3707101Medicaid
VA179765OtherANTHEM PROVIER #
4338099OtherAETNA#
VA010178835Medicaid
TN4107515OtherBCBS TN