Provider Demographics
NPI:1639131022
Name:MARTIN, DAVID ANSON JR (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANSON
Last Name:MARTIN
Suffix:JR
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:619 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3707
Practice Address - Country:US
Practice Address - Phone:910-642-0331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9501329207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8954198Medicaid
SCN01320Medicaid
NC1639131022Medicaid
NCG20499Medicare UPIN
NCNCD060BMedicare PIN
NC1639131022Medicaid
NCNCD060AMedicare PIN