Provider Demographics
NPI:1083745558
Name:MARTIN, THOMAS FOSTER JR (CPO)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:FOSTER
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HOBBY LN
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3547
Mailing Address - Country:US
Mailing Address - Phone:864-224-5446
Mailing Address - Fax:864-231-7374
Practice Address - Street 1:1113 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-4819
Practice Address - Country:US
Practice Address - Phone:864-225-1683
Practice Address - Fax:864-231-7374
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12452887451744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1943Medicaid
GA00926428AOtherGEORGIA MEDICAID
SC4227850001Medicare ID - Type Unspecified
GA00926428AOtherGEORGIA MEDICAID