Provider Demographics
NPI:1285671735
Name:KRESHON, MARTIN JOHN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JOHN
Last Name:KRESHON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-343-9800
Mailing Address - Fax:704-347-2011
Practice Address - Street 1:1640 E ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4017
Practice Address - Country:US
Practice Address - Phone:704-226-0599
Practice Address - Fax:704-226-0599
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34065207RC0000X
SC19297207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5031BOtherBCBS
NCP00612427OtherRR MEDICARE
NCP00728483OtherRR MEDICARE SANGER
SCN34065Medicaid
NC895031BMedicaid
NC2161280GMedicare PIN
NCA99503Medicare UPIN
SCA995037772Medicare PIN
NCP00612427OtherRR MEDICARE
NCP00728483OtherRR MEDICARE SANGER
NCA99503Medicare UPIN
NC2161280EMedicare PIN