Provider Demographics
NPI:1215948260
Name:MARTIN, EARL T (MD)
Entity type:Individual
Prefix:MR
First Name:EARL
Middle Name:T
Last Name:MARTIN
Suffix:
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 1:218 QUARTERMAN ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501
Mailing Address - Country:US
Mailing Address - Phone:912-287-0301
Mailing Address - Fax:912-287-1568
Practice Address - Street 1:218 QUARTERMAN ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501
Practice Address - Country:US
Practice Address - Phone:912-287-9140
Practice Address - Fax:912-287-1059
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028602207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52407006OtherBLUE CROSS BLUE SHIELD GA
GA10053757Medicaid
GAGRP2665OtherEMPLOYER ID
GA000324156IMedicaid
GA000324156IMedicaid
080184973Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE
GA000324156CMedicaid
GA000324156FMedicaid
GA10053757Medicaid
GA000324156DMedicaid
GA08BBWSNMedicare PIN