Provider Demographics
NPI:1386692523
Name:BLUE, MARTIN L (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:L
Last Name:BLUE
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 1:134 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5599
Mailing Address - Country:US
Mailing Address - Phone:704-235-6610
Mailing Address - Fax:704-235-6615
Practice Address - Street 1:134 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5599
Practice Address - Country:US
Practice Address - Phone:704-235-6610
Practice Address - Fax:704-235-6615
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G66219Medicare UPIN