Provider Demographics
NPI:1841260817
Name:MARTIN, JAMES A (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:A
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 1:11398 OREGON CIR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2496
Mailing Address - Country:US
Mailing Address - Phone:810-629-7052
Mailing Address - Fax:
Practice Address - Street 1:102 N ADELAIDE ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2670
Practice Address - Country:US
Practice Address - Phone:810-629-2245
Practice Address - Fax:810-629-6535
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301022219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1116870Medicaid
MI0255600OtherBLUE CROSS & BCN ID #
MI0856001OtherHEALTHPLUS ID #
MIC2331OtherMCARE ID #
MI1002568OtherMCLAREN HEALTH PLAN ID #
MI1116870Medicaid
MIE00464Medicare UPIN