Provider Demographics
NPI:1548556442
Name:MARTIN, TERRISSA CORETTA (MD)
Entity Type:Individual
Prefix:
First Name:TERRISSA
Middle Name:CORETTA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:85 SOUTH WEST STREET
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077
Mailing Address - Country:US
Mailing Address - Phone:607-753-3797
Mailing Address - Fax:607-753-6677
Practice Address - Street 1:20 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:NY
Practice Address - Zip Code:13803
Practice Address - Country:US
Practice Address - Phone:607-849-3271
Practice Address - Fax:607-849-6357
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY261220-1207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03759579Medicaid