Provider Demographics
NPI:1497133342
Name:MARTIN, THERESA (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
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 110
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NY
Mailing Address - Zip Code:14505-0110
Mailing Address - Country:US
Mailing Address - Phone:315-926-7733
Mailing Address - Fax:315-926-0731
Practice Address - Street 1:3669 COUNTRYSIDE LN
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NY
Practice Address - Zip Code:14505
Practice Address - Country:US
Practice Address - Phone:315-926-7733
Practice Address - Fax:315-926-0731
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY295038207Q00000X
PAMT208807390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine