Provider Demographics
NPI:1184791618
Name:MARTIN, SUSAN M (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
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:PO BOX 3868
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47737-3868
Mailing Address - Country:US
Mailing Address - Phone:812-649-5061
Mailing Address - Fax:812-649-5224
Practice Address - Street 1:3434 W STATE ROAD 66
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:IN
Practice Address - Zip Code:47635-9259
Practice Address - Country:US
Practice Address - Phone:812-649-5061
Practice Address - Fax:812-649-5224
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032026A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64756786OtherKY MEDICAID
IL000000109430OtherANTHEM
IN100189280Medicaid
KY64756786OtherKY MEDICAID
IND95009Medicare UPIN
IN750580AMedicare PIN
IN257900NNMedicare PIN