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General NPI Number Information
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NPI Number | 1023579190
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Entity Type | Individual
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Provider Name | MATTHEW MARTIN
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Gender | Male
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Dates
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Enumeration Date | 03/29/2019
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Last Update Date | 08/08/2025
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Provider Practice Location Address
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Address Line | 1220 JEFFERSON ST
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City | LAUREL
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State | MS
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Zip | 39440-4355
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Country | US
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Telephone | 601-428-0100
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Fax | 601-428-0100
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Provider Business Mailing Address
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Address Line | 585 CLUBHOUSE DR
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City | PEARL
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State | MS
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Zip | 39208-9506
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Country | US
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Telephone | 601-433-9222
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 32831
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License Number State | MS
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