Provider Demographics
NPI:1376737114
Name:MARTIN, JUAN MICHELLE (DPT)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:MICHELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:JUAN
Other - Middle Name:MICHELLE
Other - Last Name:BOVELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:480 CONGRESS PKWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4579
Mailing Address - Country:US
Mailing Address - Phone:718-916-1406
Mailing Address - Fax:
Practice Address - Street 1:480 CONGRESS PKWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-4579
Practice Address - Country:US
Practice Address - Phone:718-916-1406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0095992251X0800X
NY0296612251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY712781OtherMPN
NYQ579A1OtherBCBS
NY2854827OtherUNITED HEALTH (UHC)
NYQ579A1OtherBCBS