Provider Demographics
NPI:1679692396
Name:MARTIN, REGINALD WILLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:WILLIS
Last Name:MARTIN
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:PO BOX 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4749
Mailing Address - Fax:601-200-5929
Practice Address - Street 1:971 LAKELAND DR STE 211
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4607
Practice Address - Country:US
Practice Address - Phone:601-200-4350
Practice Address - Fax:601-200-4356
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS 13610208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01151405OtherRAILROAD MEDICARE
MS00112817Medicaid
MS020000282Medicare ID - Type Unspecified
MS00112817Medicaid
MS302I025754Medicare PIN