Provider Demographics
NPI:1528040623
Name:MARTIN, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-667-6750
Mailing Address - Fax:704-667-6751
Practice Address - Street 1:6115 PARK SOUTH DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3281
Practice Address - Country:US
Practice Address - Phone:704-554-8787
Practice Address - Fax:704-554-8774
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252860207R00000X
NC33863207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN33863Medicaid
NC1528040623Medicaid
NC1528040623Medicaid
VAP01156753Medicare PIN
E76150Medicare UPIN
NCNCH739AMedicare PIN