Provider Demographics
NPI:1134179294
Name:MARTIN, DANIEL CLYDE (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:CLYDE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAN
Other - Middle Name:C
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:880 MADISON AVE
Mailing Address - Street 2:ROOM 3E14
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3409
Mailing Address - Country:US
Mailing Address - Phone:901-515-3800
Mailing Address - Fax:901-515-3899
Practice Address - Street 1:880 MADISON AVE
Practice Address - Street 2:ROOM 3E14
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3409
Practice Address - Country:US
Practice Address - Phone:901-515-3800
Practice Address - Fax:901-515-3899
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10855207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B59349Medicare UPIN