Provider Demographics
NPI:1356381834
Name:MARTIN, LAURA SUSAN (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SUSAN
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 1:3333 CAPITAL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4513
Mailing Address - Country:US
Mailing Address - Phone:850-431-7021
Mailing Address - Fax:850-431-6975
Practice Address - Street 1:3333 CAPITAL OAKS DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4513
Practice Address - Country:US
Practice Address - Phone:850-431-4041
Practice Address - Fax:850-431-4471
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43734207SG0201X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278957400Medicaid
GA102212446AMedicaid
GA102212446AOtherMEDICAID
GA102212446AOtherMEDICAID