Healthcare Provider Details

I. General information

NPI: 1295778595
Provider Name (Legal Business Name): MICHAEL MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2235 CEDAR LN SUITE 302
VIENNA VA
22182-5202
US

IV. Provider business mailing address

2235 CEDAR LN SUITE 302
VIENNA VA
22182-5202
US

V. Phone/Fax

Practice location:
  • Phone: 917-716-1854
  • Fax: 703-344-7309
Mailing address:
  • Phone: 917-716-1854
  • Fax: 703-344-7309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101237894
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: