Provider Demographics
NPI:1184626533
Name:PERSONS, C MARTIN (MD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:MARTIN
Last Name:PERSONS
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 1:4625 BOAT CLUB RD
Mailing Address - Street 2:SUITE 253
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-7022
Mailing Address - Country:US
Mailing Address - Phone:817-399-1622
Mailing Address - Fax:817-540-0759
Practice Address - Street 1:4625 BOAT CLUB RD
Practice Address - Street 2:SUITE 253
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7022
Practice Address - Country:US
Practice Address - Phone:817-399-1622
Practice Address - Fax:817-540-0759
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4368207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMDF4368OtherWORKERS COMP
TX4080053OtherAETNA
TX114261403Medicaid
TX00EU36Medicare PIN
TX4080053OtherAETNA
TXMDF4368OtherWORKERS COMP