Provider Demographics
NPI:1245264829
Name:MARTIN, MARY SUE (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4477 W SANDY HILL ST
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-8759
Mailing Address - Country:US
Mailing Address - Phone:352-527-1475
Mailing Address - Fax:
Practice Address - Street 1:6201 N SUNCOAST BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-6712
Practice Address - Country:US
Practice Address - Phone:352-795-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41007207P00000X
FLME100482207P00000X
GA056137207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I49337Medicare UPIN