Provider Demographics
NPI:1235197211
Name:MARTIN, BRIAN G (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:G
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:5172 MASON CORBIN CT
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4540
Practice Address - Country:US
Practice Address - Phone:239-936-7171
Practice Address - Fax:239-936-6084
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7186207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG41239Medicare UPIN
FL57409YMedicare ID - Type Unspecified