Healthcare Provider Details

I. General information

NPI: 1285633578
Provider Name (Legal Business Name): THOMAS RICHARD MARTIN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 US HIGHWAY 431
BOAZ AL
35957-1547
US

IV. Provider business mailing address

500 CORLEY AVE
BOAZ AL
35957-5954
US

V. Phone/Fax

Practice location:
  • Phone: 256-840-9834
  • Fax:
Mailing address:
  • Phone: 256-593-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00011044
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: