Healthcare Provider Details

I. General information

NPI: 1316981988
Provider Name (Legal Business Name): DOUGLAS W MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WAMPANOAG TRL SUITE 302B
RIVERSIDE RI
02915-2232
US

IV. Provider business mailing address

17 VIRGINIA AVE SUITE 107
PROVIDENCE RI
02905-4406
US

V. Phone/Fax

Practice location:
  • Phone: 401-649-4070
  • Fax: 401-649-4071
Mailing address:
  • Phone: 401-443-4992
  • Fax: 401-784-4902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD12156
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD12156
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: