Provider Demographics
NPI:1821222613
Name:MARTIN, ERICA LYN (MD)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:LYN
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 1:530 N LAFAYETTE BLVD
Mailing Address - Street 2:THE MEDICAL FOUNDATION
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 N LAFAYETTE BLVD
Practice Address - Street 2:THE MEDICAL FOUNDATION
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1004
Practice Address - Country:US
Practice Address - Phone:574-234-4176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.123363207ZP0102X
IN01073029A207ZP0102X
MI4301106547207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program