Provider Demographics
NPI:1942206214
Name:MARTIN, JACK L (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:L
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 1:415 WYNTRE LEA DR
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-2038
Mailing Address - Country:US
Mailing Address - Phone:610-331-5849
Mailing Address - Fax:
Practice Address - Street 1:415 WYNTRE LEA DR
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-2038
Practice Address - Country:US
Practice Address - Phone:610-331-5849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD022890E207RC0000X
TXM9484207RC0000X
NY129873-01207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F8997OtherMEDICARE INDIVIDUAL PTAN
TX8F8997Medicare UPIN