Provider Demographics
NPI:1578561098
Name:MARTIN, NICHOLETTE M (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLETTE
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICHOLETTE
Other - Middle Name:M
Other - Last Name:MARTIN-DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 4322
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-4322
Mailing Address - Country:US
Mailing Address - Phone:301-860-0305
Mailing Address - Fax:301-860-0307
Practice Address - Street 1:4000 MITCHELLVILLE RD
Practice Address - Street 2:SUITE B322
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3104
Practice Address - Country:US
Practice Address - Phone:301-860-0305
Practice Address - Fax:301-860-0307
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00504152081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF58391Medicare UPIN