Provider Demographics
NPI:1821295411
Name:MARTIN, BRIAN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PATRICK
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 1:1501 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4228
Mailing Address - Country:US
Mailing Address - Phone:318-675-7205
Mailing Address - Fax:318-675-6878
Practice Address - Street 1:1501 KINGS HIGHWAY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71130-3932
Practice Address - Country:US
Practice Address - Phone:318-675-7205
Practice Address - Fax:318-675-6878
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201506207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1071145Medicaid
LA4K599F600Medicare PIN
NJS32306Medicare UPIN