Healthcare Provider Details

I. General information

NPI: 1861455479
Provider Name (Legal Business Name): WILLIAM GEORGE MARTIN III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 CAMPUS PARK DR STE A
MONROE NC
28112-5284
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-288-3961
  • Fax: 704-225-0689
Mailing address:
  • Phone: 704-384-8640
  • Fax: 704-384-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9300750
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: