Provider Demographics
NPI:1780677591
Name:MARTIN, ANGELA SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:SUSAN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4230
Mailing Address - Country:US
Mailing Address - Phone:904-296-3200
Mailing Address - Fax:904-296-0069
Practice Address - Street 1:3627 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4230
Practice Address - Country:US
Practice Address - Phone:904-296-3200
Practice Address - Fax:904-296-0069
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 54467207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10352OtherBCBS
FL047132100Medicaid
FL047132100Medicaid
FL10352AMedicare PIN