Provider Demographics
NPI:1871680124
Name:MARTIN, LOUISE EVELYN (MD)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:EVELYN
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 1:11250 E 13 MILE RD
Mailing Address - Street 2:STE 2B
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2597
Mailing Address - Country:US
Mailing Address - Phone:586-751-2520
Mailing Address - Fax:586-751-7004
Practice Address - Street 1:11250 E 13 MILE RD
Practice Address - Street 2:STE 2B
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2597
Practice Address - Country:US
Practice Address - Phone:586-751-2520
Practice Address - Fax:586-751-7004
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059389174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MILM059389OtherBCBSM
MILM059389OtherBCBSM