Provider Demographics
NPI:1881042927
Name:MARTIN, VAN III
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:
Last Name:MARTIN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5865 CAPO ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-9624
Mailing Address - Country:US
Mailing Address - Phone:904-325-3315
Mailing Address - Fax:
Practice Address - Street 1:5865 CAPO ISLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-9624
Practice Address - Country:US
Practice Address - Phone:904-325-3315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist