Healthcare Provider Details

I. General information

NPI: 1588926455
Provider Name (Legal Business Name): ADAM ROSS MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE # WW279
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE # WW279
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-8178
  • Fax: 305-585-5743
Mailing address:
  • Phone: 305-585-8178
  • Fax: 305-585-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116024785
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME134624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: