Provider Demographics
NPI:1477553410
Name:MARTIN, CHARLES EDWIN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:EDWIN
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 LAWN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SELLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18960-1575
Mailing Address - Country:US
Mailing Address - Phone:215-257-5578
Mailing Address - Fax:215-257-1350
Practice Address - Street 1:700 LAWN AVE
Practice Address - Street 2:
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1548
Practice Address - Country:US
Practice Address - Phone:215-257-5578
Practice Address - Fax:215-257-1350
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065165L2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01833378Medicaid
PA014550Medicare ID - Type Unspecified
PA01833378Medicaid