Provider Demographics
NPI:1568636967
Name:DERRICK J MARTIN MD PA
Entity Type:Organization
Organization Name:DERRICK J MARTIN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:352-751-8833
Mailing Address - Street 1:1501 N US HIGHWAY 441
Mailing Address - Street 2:BLDG 1800 SUITE 1832
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8999
Mailing Address - Country:US
Mailing Address - Phone:352-751-8833
Mailing Address - Fax:
Practice Address - Street 1:1501 N US HIGHWAY 441
Practice Address - Street 2:BLDG 1800 SUITE 1832
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32159-8999
Practice Address - Country:US
Practice Address - Phone:352-751-8833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100133282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0803330Medicaid
OH0803330Medicaid
OH0680526Medicare PIN