Provider Demographics
NPI:1306415468
Name:ISAAC, MARTAVIS
Entity Type:Individual
Prefix:
First Name:MARTAVIS
Middle Name:
Last Name:ISAAC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 OAK ST
Mailing Address - Street 2:
Mailing Address - City:SOPERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30457-2736
Mailing Address - Country:US
Mailing Address - Phone:478-290-7167
Mailing Address - Fax:
Practice Address - Street 1:130 OAK ST
Practice Address - Street 2:
Practice Address - City:SOPERTON
Practice Address - State:GA
Practice Address - Zip Code:30457-2736
Practice Address - Country:US
Practice Address - Phone:478-290-7167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator