Provider Demographics
NPI:1982724019
Name:MARTIN, LOURDES ECHENIQUE (MD)
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:ECHENIQUE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 GODWIN BLVD STE 360
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8153
Mailing Address - Country:US
Mailing Address - Phone:757-934-4821
Mailing Address - Fax:
Practice Address - Street 1:2790 GODWIN BLVD STE 360
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8153
Practice Address - Country:US
Practice Address - Phone:757-934-4821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051494208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA200456OtherANTHEM BC BS NUMBER
VA200456OtherANTHEM BC BS NUMBER
F88311Medicare UPIN
VAVAA103355Medicare PIN