Provider Demographics
NPI:1538143094
Name:MARTIN, REAL (MD)
Entity Type:Individual
Prefix:MR
First Name:REAL
Middle Name:
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 1:7710 NW 71ST CT STE 303
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-2932
Mailing Address - Country:US
Mailing Address - Phone:954-592-5718
Mailing Address - Fax:
Practice Address - Street 1:5355 LYONS ROAD
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073
Practice Address - Country:US
Practice Address - Phone:954-570-9595
Practice Address - Fax:954-354-8151
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53232208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL07439Medicare ID - Type Unspecified
D51922Medicare UPIN