Healthcare Provider Details

I. General information

NPI: 1265858161
Provider Name (Legal Business Name): MARTHA WILLIS COLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2014
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107A BROOKDALE ST
MARTINSVILLE VA
24112-4501
US

IV. Provider business mailing address

1107A BROOKDALE ST
MARTINSVILLE VA
24112-4501
US

V. Phone/Fax

Practice location:
  • Phone: 276-670-3300
  • Fax: 276-634-0379
Mailing address:
  • Phone: 276-670-3300
  • Fax: 276-634-0379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102204889
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: