Provider Demographics
NPI:1609450485
Name:BAXTER, MARTIN MANDELA (MD)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:MANDELA
Last Name:BAXTER
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 1:1199 PRINCE AVE
Mailing Address - Street 2:#70
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1270 PRINCE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-475-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-08
Last Update Date:2022-06-09
Deactivation Date:2022-05-06
Deactivation Code:
Reactivation Date:2022-06-09
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program