=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417954298
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHANNES KARL MARTENSSON M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2005
-----------------------------------------------------
Last Update Date | 09/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3653 E FOREST DR
-----------------------------------------------------
City | INVERNESS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34453-0787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-344-8080
-----------------------------------------------------
Fax | 352-344-0631
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3653 E FOREST DR
-----------------------------------------------------
City | INVERNESS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34453-0787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-344-8080
-----------------------------------------------------
Fax | 352-344-0631
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | ME71187
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------