Provider Demographics
NPI:1265858161
Name:COLE, MARTHA WILLIS
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:WILLIS
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107A BROOKDALE ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-4501
Mailing Address - Country:US
Mailing Address - Phone:276-670-3300
Mailing Address - Fax:276-634-0379
Practice Address - Street 1:1107A BROOKDALE ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-4501
Practice Address - Country:US
Practice Address - Phone:276-670-3300
Practice Address - Fax:276-634-0379
Is Sole Proprietor?:No
Enumeration Date:2014-03-16
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204889207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine