Provider Demographics
NPI:1396838157
Name:MARTIN, MARY KAREN (BS, DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:KAREN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:BS, DC
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 225
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-0003
Mailing Address - Country:US
Mailing Address - Phone:662-349-2650
Mailing Address - Fax:662-349-4495
Practice Address - Street 1:7464 TCHULAHOMA RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9249
Practice Address - Country:US
Practice Address - Phone:662-349-2650
Practice Address - Fax:662-349-4495
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS661111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS8732762003OtherCIGNA
MS4350358OtherAETNA
TN0053873OtherBLUE CROSS
MST20765Medicare UPIN
MS4350358OtherAETNA
MS350000028Medicare ID - Type Unspecified