Provider Demographics
NPI:1235287996
Name:MARTIN, WILMONT GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:WILMONT
Middle Name:GREGORY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1871 SAVAGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4726
Mailing Address - Country:US
Mailing Address - Phone:843-766-6308
Mailing Address - Fax:843-804-9883
Practice Address - Street 1:1818 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-3239
Practice Address - Country:US
Practice Address - Phone:843-766-6308
Practice Address - Fax:866-533-4473
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57-011973208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH57-011973OtherTRAINING CERTIFICATE
SC352843Medicaid