Healthcare Provider Details

I. General information

NPI: 1124412234
Provider Name (Legal Business Name): CHARLES C MARTIN IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 06/30/2025
Certification Date: 06/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 14TH ST
MERIDIAN MS
39301-4458
US

IV. Provider business mailing address

PO BOX 649105
DALLAS TX
75264-9105
US

V. Phone/Fax

Practice location:
  • Phone: 601-482-9224
  • Fax: 601-482-9223
Mailing address:
  • Phone: 601-207-7093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number24993
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number24993
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number24993
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: