Provider Demographics
NPI:1750461349
Name:MARTIN, ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
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 1:1285 SIMS ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3851
Mailing Address - Country:US
Mailing Address - Phone:770-536-0149
Mailing Address - Fax:770-536-0317
Practice Address - Street 1:1285 SIMS ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3851
Practice Address - Country:US
Practice Address - Phone:770-536-0149
Practice Address - Fax:770-536-0317
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016639207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00162731BMedicaid
GAD02556Medicare UPIN