Provider Demographics
NPI:1477570927
Name:MARTIN, ANTHONY KEITH (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:KEITH
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:A
Other - Middle Name:KEITH
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:330 HOSPITAL DR BLDG C STE 315
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3899
Mailing Address - Country:US
Mailing Address - Phone:478-750-8606
Mailing Address - Fax:478-750-0470
Practice Address - Street 1:330 HOSPITAL DR BLDG C STE 315
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217
Practice Address - Country:US
Practice Address - Phone:478-750-8606
Practice Address - Fax:478-750-0470
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA36815208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00544629BMedicaid
G53643Medicare UPIN
GA00544629BMedicaid