Provider Demographics
NPI:1497710008
Name:MARTIN, LARRY E (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:E
Last Name:MARTIN
Suffix:
Gender:M
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 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5753
Practice Address - Street 1:4003 KRESGE WAY
Practice Address - Street 2:STE 228
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207
Practice Address - Country:US
Practice Address - Phone:502-893-5100
Practice Address - Fax:502-893-8408
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19096207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64190960Medicaid
C10892OtherRR MC GRP
KY00162033Medicare PIN
KY64190960Medicaid