Provider Demographics
NPI:1689366262
Name:MARTIN, DAVIS
Entity Type:Individual
Prefix:
First Name:DAVIS
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 AYCOCK CEMETERY ROAD
Mailing Address - Street 2:
Mailing Address - City:LEIGHTON
Mailing Address - State:AL
Mailing Address - Zip Code:35646
Mailing Address - Country:US
Mailing Address - Phone:970-417-7462
Mailing Address - Fax:
Practice Address - Street 1:4580 TOWNE LAKE PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5521
Practice Address - Country:US
Practice Address - Phone:678-771-6459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL489346225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist