Healthcare Provider Details

I. General information

NPI: 1366973885
Provider Name (Legal Business Name): ANDREW THOMAS MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2017
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

PO BOX 750243
DAYTON OH
45475-0243
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-3118
  • Fax:
Mailing address:
  • Phone: 937-709-5051
  • Fax: 937-709-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.145049
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: