Provider Demographics
NPI:1609450485
Name:BAXTER, MARTIN MANDELA (MD)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:MANDELA
Last Name:BAXTER
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 1:2084 HEADLAND DR
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-2135
Mailing Address - Country:US
Mailing Address - Phone:404-965-5691
Mailing Address - Fax:404-698-1478
Practice Address - Street 1:2084 HEADLAND DR
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-2135
Practice Address - Country:US
Practice Address - Phone:404-965-5691
Practice Address - Fax:404-698-1478
Is Sole Proprietor?:No
Enumeration Date:2021-05-08
Last Update Date:2024-05-06
Deactivation Date:2022-05-06
Deactivation Code:
Reactivation Date:2022-06-09
Provider Licenses
StateLicense IDTaxonomies
GA98019207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine