Provider Demographics
NPI:1992730832
Name:MARTIN, JERRY WAYNE (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:WAYNE
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:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22747-0269
Mailing Address - Country:US
Mailing Address - Phone:540-675-3316
Mailing Address - Fax:540-675-3692
Practice Address - Street 1:338 GAY STREET
Practice Address - Street 2:SUITE A
Practice Address - City:WASHINGTON
Practice Address - State:VA
Practice Address - Zip Code:22747-0269
Practice Address - Country:US
Practice Address - Phone:540-675-3316
Practice Address - Fax:540-675-3692
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101020616207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA175551OtherANTHEM BCBS
VA175551OtherANTHEM BCBS