Provider Demographics
NPI:1386207793
Name:AVERA, MARTY DAVID
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:DAVID
Last Name:AVERA
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 1:90 HEAD RD
Mailing Address - Street 2:
Mailing Address - City:JULIETTE
Mailing Address - State:GA
Mailing Address - Zip Code:31046-3445
Mailing Address - Country:US
Mailing Address - Phone:478-258-7226
Mailing Address - Fax:
Practice Address - Street 1:275 SHERATON BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1359
Practice Address - Country:US
Practice Address - Phone:478-258-7226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies