Healthcare Provider Details

I. General information

NPI: 1356520647
Provider Name (Legal Business Name): THOMAS CHARLES MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 AIRPORT RD
WATERVILLE ME
04901-4524
US

IV. Provider business mailing address

40 AIRPORT RD
WATERVILLE ME
04901-4524
US

V. Phone/Fax

Practice location:
  • Phone: 207-742-8381
  • Fax:
Mailing address:
  • Phone: 207-742-8381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberMD17607
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number017607
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberMD17607
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: