Provider Demographics
NPI:1376561324
Name:PRICE, MARTIE LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIE
Middle Name:LEE
Last Name:PRICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARTIE
Other - Middle Name:LEE
Other - Last Name:JEWEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5960 FAIRVIEW RD STE 500
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3113
Mailing Address - Country:US
Mailing Address - Phone:704-495-6334
Mailing Address - Fax:704-817-7219
Practice Address - Street 1:16817 MARVIN ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-495-6036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001172207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0117AMedicaid
NC137CAOtherBLUE CROSS BLUE SHIELD
NC1376561324Medicaid
NC89137CAMedicaid
NC2027438Medicare PIN
NC1376561324Medicaid
I07472Medicare UPIN