Healthcare Provider Details

I. General information

NPI: 1598968133
Provider Name (Legal Business Name): MARY JO MARTIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARSHALL ST PATHOLOGY
RICHMOND VA
23298-5051
US

IV. Provider business mailing address

PO BOX 91734
RICHMOND VA
23291-1734
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-9737
  • Fax:
Mailing address:
  • Phone: 804-358-6100
  • Fax: 804-342-7619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number0101233525
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0101233525
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: