Healthcare Provider Details

I. General information

NPI: 1174908230
Provider Name (Legal Business Name): JONATHAN MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TRILLIUM WAY
CORBIN KY
40701-8727
US

IV. Provider business mailing address

5200 COMMERCE CROSSINGS DR
LOUISVILLE KY
40229-2182
US

V. Phone/Fax

Practice location:
  • Phone: 606-523-8521
  • Fax: 606-523-8742
Mailing address:
  • Phone: 502-253-4966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberR3842
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number52464
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: