Healthcare Provider Details

I. General information

NPI: 1679692396
Provider Name (Legal Business Name): REGINALD WILLIS MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 211
JACKSON MS
39216-4607
US

IV. Provider business mailing address

PO BOX 23666
JACKSON MS
39225-3666
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-4350
  • Fax: 601-200-4356
Mailing address:
  • Phone: 601-200-4749
  • Fax: 601-200-5929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMS 13610
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: