Provider Demographics
NPI:1942379573
Name:MARTIN, JEFFREY M
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
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 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:46440 BENEDICT DR
Practice Address - Street 2:SUITE 107
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-6602
Practice Address - Country:US
Practice Address - Phone:703-450-1125
Practice Address - Fax:703-450-1145
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101222441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1942379573Medicaid
VA1942379573Medicaid
VAMC10264Medicare PIN