Healthcare Provider Details

I. General information

NPI: 1467643221
Provider Name (Legal Business Name): SEAN NICHOLAS MARTIN D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 03/19/2021
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17425 7TH ST STE 560174
MONTVERDE FL
34756-3206
US

IV. Provider business mailing address

17425 7TH ST STE 560174
MONTVERDE FL
34756-3206
US

V. Phone/Fax

Practice location:
  • Phone: 407-544-0166
  • Fax:
Mailing address:
  • Phone: 407-544-0166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS10526
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: