Provider Demographics
NPI:1437245107
Name:MARTIN, PAUL TIMOTHY (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:TIMOTHY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 MILLBRANCH RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1420
Mailing Address - Country:US
Mailing Address - Phone:662-342-1107
Mailing Address - Fax:662-280-0178
Practice Address - Street 1:9040 MILLBRANCH RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1420
Practice Address - Country:US
Practice Address - Phone:662-342-1107
Practice Address - Fax:662-280-0178
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS754111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS6443272001OtherCIGNA
TN0123504OtherBC/TN
MS4350351OtherAETNA
MS4350351OtherAETNA
MS350000052Medicare ID - Type Unspecified
MS35003502Medicare ID - Type UnspecifiedRAILROAD