Provider Demographics
NPI:1710551460
Name:MARTIN, RONALD ALAN JR (PROGRAM SPONSOR)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:ALAN
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:PROGRAM SPONSOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 KINGS HWY N
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1919
Mailing Address - Country:US
Mailing Address - Phone:856-651-7826
Mailing Address - Fax:856-229-7142
Practice Address - Street 1:1305 KINGS HWY N
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1919
Practice Address - Country:US
Practice Address - Phone:856-651-7826
Practice Address - Fax:856-229-7142
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2000872261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2000872Medicaid