Provider Demographics
NPI:1861607467
Name:LAIRD, MARTIN LUTHER IV (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:LUTHER
Last Name:LAIRD
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6103 BAYOU ROBERT DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-2663
Mailing Address - Country:US
Mailing Address - Phone:318-229-9238
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12164R207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1695874Medicaid
LA54422Medicare ID - Type Unspecified
LA646488Medicare UPIN