Healthcare Provider Details

I. General information

NPI: 1518177740
Provider Name (Legal Business Name): MR. MARTIN LAMAR GUNN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 N FRASER ST
GEORGETOWN SC
29440-3265
US

IV. Provider business mailing address

605 N FRASER ST
GEORGETOWN SC
29440-3265
US

V. Phone/Fax

Practice location:
  • Phone: 843-545-9999
  • Fax: 843-545-1099
Mailing address:
  • Phone: 843-545-9999
  • Fax: 843-545-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberC15792
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: