Provider Demographics
NPI:1144296963
Name:DAVID EUGENE MARTIN MD PC
Entity type:Organization
Organization Name:DAVID EUGENE MARTIN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-845-3175
Mailing Address - Street 1:102 WOODCHASE
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-9734
Mailing Address - Country:US
Mailing Address - Phone:706-885-1349
Mailing Address - Fax:706-845-3094
Practice Address - Street 1:1514 VERNON RD
Practice Address - Street 2:WEST GEORGIA HEALTH SYSTEM
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4131
Practice Address - Country:US
Practice Address - Phone:706-845-3175
Practice Address - Fax:706-845-3094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300032215BMedicaid
GACB8938Medicare PIN
GAGRP2561Medicare PIN