Healthcare Provider Details

I. General information

NPI: 1184369712
Provider Name (Legal Business Name): JAMES WILLIAM MARTIN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 E BROADWAY AVE
MARYVILLE TN
37804-2913
US

IV. Provider business mailing address

1617 E BROADWAY AVE
MARYVILLE TN
37804-2913
US

V. Phone/Fax

Practice location:
  • Phone: 865-982-8557
  • Fax: 865-982-8599
Mailing address:
  • Phone: 865-982-8557
  • Fax: 865-982-8599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number0000002087
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: