Healthcare Provider Details

I. General information

NPI: 1275722977
Provider Name (Legal Business Name): CHARLES MARTIN III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE L10
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

9500 EUCLID AVE L10
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-0617
  • Fax: 216-445-1492
Mailing address:
  • Phone: 216-444-0617
  • Fax: 216-445-1492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA08766900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD439930
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD439930
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number25MA08766900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: