Healthcare Provider Details

I. General information

NPI: 1568769180
Provider Name (Legal Business Name): MARTIN JOEL HALLAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2011
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5985 SILVER FALLS RUN STE 100
BRADENTON FL
34211-1291
US

IV. Provider business mailing address

PO BOX 748817
ATLANTA GA
30374-8817
US

V. Phone/Fax

Practice location:
  • Phone: 941-202-2055
  • Fax: 877-550-1635
Mailing address:
  • Phone: 132-860-0338
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number02005234A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOS13171
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: