Provider Demographics
NPI:1104269463
Name:MARTELL, MATTHEW HARRISON (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:HARRISON
Last Name:MARTELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 PINE ST STE 500
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7530
Mailing Address - Country:US
Mailing Address - Phone:478-633-8682
Mailing Address - Fax:478-633-8698
Practice Address - Street 1:840 PINE ST STE 500
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7530
Practice Address - Country:US
Practice Address - Phone:478-633-8682
Practice Address - Fax:478-633-8698
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA079422207X00000X
390200000X
GA79422207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program