Healthcare Provider Details

I. General information

NPI: 1013073477
Provider Name (Legal Business Name): NIELS DOUGLAS MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N 39TH ST
PHILADELPHIA PA
19104-2640
US

IV. Provider business mailing address

51 N 39TH ST
PHILADELPHIA PA
19104-2640
US

V. Phone/Fax

Practice location:
  • Phone: 215-349-8310
  • Fax: 215-724-3560
Mailing address:
  • Phone: 215-349-8310
  • Fax: 215-724-3560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD420992
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD420992
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMD420992
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: