Provider Demographics
NPI:1578595831
Name:MARTIN, DAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:C
Last Name:MARTIN
Suffix:
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 1:455 PHILIP BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-8768
Mailing Address - Country:US
Mailing Address - Phone:770-962-3642
Mailing Address - Fax:770-962-3643
Practice Address - Street 1:1008 DRUID PARK AVE STE 101
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5848
Practice Address - Country:US
Practice Address - Phone:770-962-3642
Practice Address - Fax:770-962-3643
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024031207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG24031Medicaid
GA550789920OtherTRICARE
GA000288626EMedicaid
GA050090631OtherRRMEDICARE
GA000288626FMedicaid
GA339275OtherWELLCARE CMO
GA048398OtherBCBS
GA048398OtherBCBS
GA000288626EMedicaid