Provider Demographics
NPI:1750619243
Name:MARTIN, SCOTT LANIER (DO)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:LANIER
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19400 N CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60411-9608
Mailing Address - Country:US
Mailing Address - Phone:708-474-0410
Mailing Address - Fax:708-474-0328
Practice Address - Street 1:1040 SIERRA DR
Practice Address - Street 2:STE 400
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-7240
Practice Address - Country:US
Practice Address - Phone:317-528-4248
Practice Address - Fax:317-865-8314
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036124986207QS0010X
IN02003798A207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty