Healthcare Provider Details

I. General information

NPI: 1124225065
Provider Name (Legal Business Name): WALLACE F. MARTIN, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PROFESSIONAL DR SUITE 300
LAWRENCEVILLE GA
30046-3371
US

IV. Provider business mailing address

631 PROFESSIONAL DRIVE SUITE 300
LAWRENCEVILLE GA
30046-3371
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-9977
  • Fax: 770-339-9804
Mailing address:
  • Phone: 770-962-9977
  • Fax: 770-339-9804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number026153
License Number StateGA

VIII. Authorized Official

Name: WALLACE FORD MARTIN
Title or Position: OWNER
Credential: M.D.
Phone: 770-962-9977