Provider Demographics
NPI:1982896296
Name:MARTIN, MARY LOUISE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOUISE
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:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-0276
Mailing Address - Country:US
Mailing Address - Phone:626-394-3198
Mailing Address - Fax:225-654-8750
Practice Address - Street 1:3223 8TH ST
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-1623
Practice Address - Country:US
Practice Address - Phone:504-833-7770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99897207P00000X
LAMD.203324207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0080563Medicaid
P00787988OtherRAILROAD MCARE THRU PEPA
LA0080563Medicaid