Healthcare Provider Details

I. General information

NPI: 1700869740
Provider Name (Legal Business Name): JAMEL ALPHONSO MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 10/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8415 GOODWOOD BLVD SUITE 104
BATON ROUGE LA
70806-7851
US

IV. Provider business mailing address

8415 GOODWOOD BLVD SUITE 104
BATON ROUGE LA
70806-7851
US

V. Phone/Fax

Practice location:
  • Phone: 225-925-9797
  • Fax: 225-925-9787
Mailing address:
  • Phone: 225-925-9797
  • Fax: 225-925-9787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.024319
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: