Healthcare Provider Details

I. General information

NPI: 1750329918
Provider Name (Legal Business Name): GARY L. MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S CENTER ST
HILDEBRAN NC
28637-8304
US

IV. Provider business mailing address

PO BOX 829
HILDEBRAN NC
28637-0829
US

V. Phone/Fax

Practice location:
  • Phone: 828-397-3522
  • Fax: 828-397-3522
Mailing address:
  • Phone: 828-397-3522
  • Fax: 828-397-3522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101059276
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number138795
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: