Provider Demographics
NPI:1669465134
Name:MARTIN, CAROLYN M (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 2007B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-991-5000
Mailing Address - Fax:314-991-5035
Practice Address - Street 1:621 S NEW BALLAS RD STE 2007B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8265
Practice Address - Country:US
Practice Address - Phone:314-991-5000
Practice Address - Fax:314-991-5035
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR7824207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200990844Medicaid
MOA28904Medicare UPIN
MO200990844Medicaid