Healthcare Provider Details

I. General information

NPI: 1689322604
Provider Name (Legal Business Name): JUSTIN R MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LIELMANIS AVE
HURLBURT FIELD FL
32544-5613
US

IV. Provider business mailing address

3551 ROGER BROOKE DR.
JBSA-FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 850-881-1020
  • Fax:
Mailing address:
  • Phone: 210-292-7805
  • Fax: 210-292-7868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: