Provider Demographics
NPI:1164501011
Name:MARTIN, FREDERICK W (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
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 1:119 AMBULANCE DR 202
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:770-838-8563
Practice Address - Street 1:109 PROFESSIONAL PL
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3862
Practice Address - Country:US
Practice Address - Phone:770-834-0170
Practice Address - Fax:770-214-1546
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022595207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
52150678001OtherBLUE CROSS BLUE SHIELD
GA00223253AMedicaid
GA000223253AOtherPEACH STATE
52150678001OtherBLUE CROSS BLUE SHIELD
52150678001OtherBLUE CROSS BLUE SHIELD