Provider Demographics
NPI:1114489507
Name:MARTIN, JOHN LLOYD
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LLOYD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7283
Mailing Address - Country:US
Mailing Address - Phone:601-261-1500
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:7148 U S HIGHWAY 98 STE 101
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-9133
Practice Address - Country:US
Practice Address - Phone:601-261-1500
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS29293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty