Provider Demographics
NPI:1831128180
Name:MARTIN, JOHN DAVID (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 HEALTH PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7383
Mailing Address - Country:US
Mailing Address - Phone:810-953-0500
Mailing Address - Fax:810-953-0031
Practice Address - Street 1:861 HEALTH PARK BLVD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7383
Practice Address - Country:US
Practice Address - Phone:810-953-0500
Practice Address - Fax:810-953-0031
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008124207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4592053Medicaid
MI4592053Medicaid
MIB45351Medicare UPIN