Provider Demographics
NPI:1760678189
Name:MARTIN, EDWARD L (MLT-ASCP)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MLT-ASCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 JOHN DR
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-9545
Mailing Address - Country:US
Mailing Address - Phone:505-434-3139
Mailing Address - Fax:
Practice Address - Street 1:5901 BROKEN SOUND PKWY
Practice Address - Street 2:STE. 500
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2773
Practice Address - Country:US
Practice Address - Phone:561-367-1175
Practice Address - Fax:561-892-3234
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMLT-51881246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other