Provider Demographics
NPI:1912013665
Name:MARTIN, DAVID C (MD,PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD,PA
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 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:
Practice Address - Street 1:619 S FLEISHEL AVE STE 201
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2004
Practice Address - Country:US
Practice Address - Phone:903-606-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052410207Q00000X
TXK9119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX031355303Medicaid
TX75-2616977-007OtherTRICARE
TX031355302Medicaid
TX75-2616977-108OtherTRICARE
TX752616977118OtherTRICARE
GA460041120AMedicaid
TX8DB081OtherBCBS
TX8DC095OtherBCBS
TXP01029750Medicare PIN
TX75-2616977-007OtherTRICARE
TX031355302Medicaid
TX8DC095OtherBCBS
TX75-2616977-108OtherTRICARE
GAH06489Medicare UPIN