Provider Demographics
NPI:1962996140
Name:MARTIN, JEREMY SCOTT
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:MARTIN
Suffix:
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:PO BOX 3146
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33780-3146
Mailing Address - Country:US
Mailing Address - Phone:727-276-2579
Mailing Address - Fax:
Practice Address - Street 1:2481 N.E. COACHMAN RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765
Practice Address - Country:US
Practice Address - Phone:727-797-9756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021020300Medicaid