Provider Demographics
NPI:1801886585
Name:MARTIN, ROBERT TATE (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:TATE
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 1:1811 E BERT KOUNS INDUSTRIAL LOOP # 210
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5740
Mailing Address - Country:US
Mailing Address - Phone:318-212-3858
Mailing Address - Fax:318-212-3958
Practice Address - Street 1:1811 E BERT KOUNS INDUSTRIAL LOOP # 210
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-212-3858
Practice Address - Fax:318-212-3958
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL#021109207RC0000X, 207RI0011X
LAMD.021109207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132212001Medicaid
TX057726401Medicaid
LA1017159Medicaid
LA060053256OtherRAILROAD MEDICARE
LA1017159Medicaid
LA060053256OtherRAILROAD MEDICARE
TX057726401Medicaid