Healthcare Provider Details

I. General information

NPI: 1639499783
Provider Name (Legal Business Name): JARED C MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 CLAYTON RD SUITE 291
SAINT LOUIS MO
63117-1811
US

IV. Provider business mailing address

6420 CLAYTON RD SUITE 291
SAINT LOUIS MO
63117-1811
US

V. Phone/Fax

Practice location:
  • Phone: 314-781-4772
  • Fax: 314-645-8771
Mailing address:
  • Phone: 314-781-4772
  • Fax: 314-645-8771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2010017742
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5488876-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: