Provider Demographics
NPI:1669432795
Name:MARTIN, LAURENCE J (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:J
Last Name:MARTIN
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 1:7543 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-6502
Mailing Address - Country:US
Mailing Address - Phone:727-868-7800
Mailing Address - Fax:727-868-7866
Practice Address - Street 1:7543 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-6502
Practice Address - Country:US
Practice Address - Phone:727-868-7800
Practice Address - Fax:727-868-7866
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073800208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254512800Medicaid
FL43665YMedicare ID - Type Unspecified
G73167Medicare UPIN
FLGRP # BD341Medicare PIN
FL43665XMedicare PIN