Provider Demographics
NPI:1558529438
Name:MARTIN, LARRY JR (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:MARTIN
Suffix:JR
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7834
Mailing Address - Fax:704-316-7110
Practice Address - Street 1:2000 WELLNESS BLVD STE 140
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-3354
Practice Address - Country:US
Practice Address - Phone:704-316-2338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43478207X00000X
IN11012750A207X00000X
OH35.095415207X00000X
NC2011-01084207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1558529438Medicaid
SCNC1461Medicaid
NC1558529438Medicaid