Provider Demographics
NPI:1255308508
Name:MARTIN, THERESA A (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
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:PO BOX 19036
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4085
Mailing Address - Country:US
Mailing Address - Phone:903-381-7263
Mailing Address - Fax:903-381-7269
Practice Address - Street 1:802 MEDICAL DR STE 200
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5201
Practice Address - Country:US
Practice Address - Phone:903-232-8297
Practice Address - Fax:903-553-7751
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6565207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105981808Medicaid
TXG44250Medicare UPIN
TX105981808Medicaid