Provider Demographics
NPI:1558344135
Name:MARTIN, LAURA MARGARET (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARGARET
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-2400
Mailing Address - Fax:215-707-4034
Practice Address - Street 1:1700 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19121
Practice Address - Country:US
Practice Address - Phone:215-204-2679
Practice Address - Fax:215-204-1784
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101717193Medicaid
DC028853600Medicaid
DC028853600Medicaid
PAE21662Medicare UPIN
DCE21662Medicare UPIN