Healthcare Provider Details

I. General information

NPI: 1881829240
Provider Name (Legal Business Name): JEREMY M MARTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4767 DRANE FIELD RD
LAKELAND FL
33811-1220
US

IV. Provider business mailing address

4767 DRANE FIELD RD
LAKELAND FL
33811-1220
US

V. Phone/Fax

Practice location:
  • Phone: 863-816-5858
  • Fax: 863-816-5837
Mailing address:
  • Phone: 863-816-5858
  • Fax: 863-816-5837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: