Provider Demographics
NPI:1881670552
Name:MONDRY, MARTIN G (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:G
Last Name:MONDRY
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 1:5665 NEW NORTHSIDE DR NW
Mailing Address - Street 2:SUITE 320
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5831
Mailing Address - Country:US
Mailing Address - Phone:770-874-5400
Mailing Address - Fax:770-874-5483
Practice Address - Street 1:1613 N MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2247
Practice Address - Country:US
Practice Address - Phone:770-874-5439
Practice Address - Fax:770-874-5483
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33096207L00000X
ALMD.30804207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00082072OtherRAILROAD
WI31895500Medicaid
F49387Medicare UPIN