Provider Demographics
NPI:1861458978
Name:MARTIN, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
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 1:717 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4580
Mailing Address - Country:US
Mailing Address - Phone:407-846-0533
Mailing Address - Fax:407-518-1730
Practice Address - Street 1:717 E OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4580
Practice Address - Country:US
Practice Address - Phone:407-846-0533
Practice Address - Fax:407-518-1730
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD400262084P0800X
FLME1527622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3333303Medicaid
TNTN01W6OtherJOHN DEERE
TNTN01W6OtherJOHN DEERE
TN3333303Medicaid