Provider Demographics
NPI:1275516999
Name:MARTIN, LILLA GAYLE (MD)
Entity Type:Individual
Prefix:DR
First Name:LILLA
Middle Name:GAYLE
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 1:1893 KINGSLEY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4491
Mailing Address - Country:US
Mailing Address - Phone:904-272-6955
Mailing Address - Fax:904-272-5001
Practice Address - Street 1:1893 KINGSLEY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4491
Practice Address - Country:US
Practice Address - Phone:904-272-6955
Practice Address - Fax:904-272-5001
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0030921207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065902900Medicaid
FL065902900Medicaid