Provider Demographics
NPI:1831175462
Name:MARTIN, CAROLYN JOHANNA (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:JOHANNA
Last Name:MARTIN
Suffix:
Gender:F
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:PO BOX 1600
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1600
Mailing Address - Country:US
Mailing Address - Phone:360-514-2142
Mailing Address - Fax:
Practice Address - Street 1:400 NE MOTHER JOESPH PLACE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-514-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25889207P00000X
ORMD27043207P00000X
IN01067726B207P00000X
WAMD 60131801207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1831175462Medicaid
MT1831175462Medicaid