Provider Demographics
NPI:1134347347
Name:MARTIN, CAROL REYBURN (MD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:REYBURN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:REYBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10017 PARK ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-1847
Mailing Address - Country:US
Mailing Address - Phone:703-947-7377
Mailing Address - Fax:703-718-5557
Practice Address - Street 1:10017 PARK ROYAL DR
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:VA
Practice Address - Zip Code:22066-1847
Practice Address - Country:US
Practice Address - Phone:037-947-7377
Practice Address - Fax:703-718-5557
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007006297207RG0300X
VA0101265405207RG0300X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO124510086Medicare PIN