Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VG0400X | Gynecologist | 00008862 | AL |
NPI | 1164489498 |
---|---|
Provider Name | Ben R Martin III |
First Address | Dothan, AL 36305-4300 |
Second Address | Dothan, AL 36305-4300 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/04/2006 |
Last Update Date | 11/03/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000010492 | (05) | AL |
C78930 | (02) |