Provider Demographics
NPI:1881672558
Name:MARTIN, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37605-0779
Mailing Address - Country:US
Mailing Address - Phone:423-928-1145
Mailing Address - Fax:423-928-1353
Practice Address - Street 1:211 BLOUNT AVE
Practice Address - Street 2:SUITE 507
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920
Practice Address - Country:US
Practice Address - Phone:865-525-0598
Practice Address - Fax:865-525-0598
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37585208M00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3886502Medicaid
TN4066540OtherBCBS
TN7688492OtherAETNA
TNP00078148OtherPALMETTO GBA-RR MCR
TN7688492OtherAETNA
TN3886502Medicare ID - Type UnspecifiedMEDICARE#