Provider Demographics
NPI:1699759860
Name:MARTIN, JEFFERY L (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:L
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 1:737 N 1550 RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-9198
Mailing Address - Country:US
Mailing Address - Phone:785-766-2158
Mailing Address - Fax:
Practice Address - Street 1:406 AMES ST
Practice Address - Street 2:
Practice Address - City:BALDWIN CITY
Practice Address - State:KS
Practice Address - Zip Code:66006-3099
Practice Address - Country:US
Practice Address - Phone:785-594-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-18249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS021119OtherBCBS OF KS
KS100138770Medicaid
KS100138770Medicaid
KSD17421Medicare UPIN