Provider Demographics
NPI:1891992376
Name:MARTIN, STEPHANIE RENEE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:RENEE
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:PO BOX 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6576
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2401 BRANDERMILL BLVD
Practice Address - Street 2:SUITE 250
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1690
Practice Address - Country:US
Practice Address - Phone:410-721-1507
Practice Address - Fax:410-721-1510
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116019263390200000X
DEC7-0004604390200000X
MDD73127207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD053826400Medicaid
DCK6440003OtherBCBS
MD97725101OtherBCBS
MD8527802OtherAETNA HMO
MD9936846OtherAETNA PPO
MD053826400Medicaid
DCK6440003OtherBCBS