Healthcare Provider Details

I. General information

NPI: 1386263267
Provider Name (Legal Business Name): MARTIN ALLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5156
US

IV. Provider business mailing address

2001 KINGSLEY AVE
ORANGE PARK FL
32073-5156
US

V. Phone/Fax

Practice location:
  • Phone: 904-639-2000
  • Fax: 904-639-2015
Mailing address:
  • Phone:
  • Fax: 904-639-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS18774
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOS18774
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: