Provider Demographics
NPI:1013073477
Name:MARTIN, NIELS DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:NIELS
Middle Name:DOUGLAS
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 1:51 N 39TH ST
Mailing Address - Street 2:MEDICAL OFFICE BUILDING, 1ST FLOOR, SUITE 120
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-662-7320
Mailing Address - Fax:215-243-4605
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:MEDICAL OFFICE BUILDING, 1ST FLOOR, SUITE 120
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-7320
Practice Address - Fax:215-243-4605
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD420992208600000X, 2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0125024Medicaid
PA1018343780005Medicaid
NJ0125024Medicaid