Provider Demographics
NPI:1255367132
Name:MARTIN, EDWARD J III (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:MARTIN
Suffix:III
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:PO BOX 731280
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1280
Mailing Address - Country:US
Mailing Address - Phone:318-841-9526
Mailing Address - Fax:
Practice Address - Street 1:1141 WHITNEY AVE
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-5011
Practice Address - Country:US
Practice Address - Phone:504-361-3757
Practice Address - Fax:504-361-3132
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018796207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1922099Medicaid
LA249592YK3NMedicare PIN
LA24952YH4EMedicare PIN
LA1922099Medicaid
LA5N741Medicare PIN
LA249592YJYPMedicare PIN