Provider Demographics
NPI:1588627103
Name:MARTIN, CAROLINE M (RD)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 BEAR LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-6620
Mailing Address - Country:US
Mailing Address - Phone:478-922-7575
Mailing Address - Fax:
Practice Address - Street 1:350 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3838
Practice Address - Country:US
Practice Address - Phone:478-965-4189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD000304133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBMVMedicare ID - Type Unspecified