Provider Demographics
NPI:1316016819
Name:MARTIN, JOHN EDWARD SR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:MARTIN
Suffix:SR
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:PO BOX 922088
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30010-2088
Mailing Address - Country:US
Mailing Address - Phone:866-795-4593
Mailing Address - Fax:866-795-4593
Practice Address - Street 1:1497 FAIR RD
Practice Address - Street 2:SUITE 103
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0822
Practice Address - Country:US
Practice Address - Phone:912-486-1163
Practice Address - Fax:866-795-4593
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA25229208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000346376BMedicaid
GAP00387675OtherMEDICARE RAILROAD
GA1073707436OtherNPI
GAP00387675OtherMEDICARE RAILROAD
GA11SCGTQMedicare PIN