Healthcare Provider Details

I. General information

NPI: 1871555029
Provider Name (Legal Business Name): SHELLY DAWN MARTIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 PENNSYLVANIA AVE
CHARLESTON WV
25302-3351
US

IV. Provider business mailing address

800 PENNSYLVANIA AVE
CHARLESTON WV
25302-3351
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-2381
  • Fax: 304-388-2640
Mailing address:
  • Phone: 304-388-2381
  • Fax: 304-388-2640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP0090
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License Number29866
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: