Provider Demographics
NPI:1841222452
Name:MARTIN, GEORGE L (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:L
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11141 PARKVIEW PLAZA DR STE 325
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1714
Practice Address - Country:US
Practice Address - Phone:260-425-5400
Practice Address - Fax:260-425-5417
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37370208800000X
IN01071495A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201081540Medicaid
IN000000776371OtherANTHEM
AZ370244Medicaid
AZP00869313OtherRAILROAD MEDICARE
IN000000776371OtherANTHEM
AZZ125213Medicare PIN