Healthcare Provider Details

I. General information

NPI: 1699759860
Provider Name (Legal Business Name): JEFFERY L MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 AMES ST
BALDWIN CITY KS
66006-3099
US

IV. Provider business mailing address

737 N 1550 RD
LAWRENCE KS
66049-9198
US

V. Phone/Fax

Practice location:
  • Phone: 785-594-2512
  • Fax:
Mailing address:
  • Phone: 785-766-2158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-18249
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: