Provider Demographics
NPI:1275579435
Name:MARTIN, ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 S GULLEY RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-1005
Mailing Address - Country:US
Mailing Address - Phone:313-792-0441
Mailing Address - Fax:
Practice Address - Street 1:24411 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1850
Practice Address - Country:US
Practice Address - Phone:124-655-0337
Practice Address - Fax:248-655-0339
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDE6518OtherPALMETTO GBA RAILROAD MR
MI133021OtherTRINITY HEALTH PLANS
MI4616478Medicaid
MINC023552OtherMCARE
MI019509OtherMIDWEST HEALTH PLAN
MI60252OtherOMNICARE
MI1108249942OtherBCBSM
MIBM5399755OtherDEA NUMBER
MIDE6518OtherPALMETTO GBA RAILROAD MR
MI4616478Medicaid