Provider Demographics
NPI:1588681118
Name:MARTIN, ELECTRA C (MD)
Entity Type:Individual
Prefix:
First Name:ELECTRA
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:540-224-5684
Practice Address - Street 1:1401 JOHNSTON WILLIS DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-4730
Practice Address - Country:US
Practice Address - Phone:804-330-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218131207P00000X
VA0101225625207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005850665Medicaid
VA005884454Medicaid
VA005850657Medicaid
VA005855799Medicaid
H23869Medicare UPIN
VA005855799Medicaid
VA930002058Medicare PIN
VA005850657Medicaid
VA001574V20Medicare PIN