Provider Demographics
NPI:1356517692
Name:MARTIN, JERMELIAH MONIQUE TODD (MD)
Entity type:Individual
Prefix:DR
First Name:JERMELIAH
Middle Name:MONIQUE TODD
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-4021
Mailing Address - Fax:704-384-5601
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-384-4021
Practice Address - Fax:704-384-5601
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2011-00863208000000X, 208M00000X
IN01068449A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1356517692Medicaid
IN200990620Medicaid
NC5919171Medicaid
NC5919171Medicaid
INM400030265Medicare PIN