Provider Demographics
NPI:1184624306
Name:MARTIN, JUSTIN L (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
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 1:1300 W TERRELL AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2810
Mailing Address - Country:US
Mailing Address - Phone:817-252-5000
Mailing Address - Fax:817-252-5060
Practice Address - Street 1:1300 W TERRELL AVE STE 500
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2810
Practice Address - Country:US
Practice Address - Phone:817-252-5000
Practice Address - Fax:817-252-5060
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2446207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174150604Medicaid
TX174150603Medicaid
TXTXB115214Medicare PIN
I25767Medicare UPIN
TX174150603Medicaid