Provider Demographics
NPI:1871597682
Name:MARTIN, LAURENCE (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
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:P.O. BOX 589
Mailing Address - Street 2:FORT DEFIANCE INDIAN HOSPITAL BOARD
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504
Mailing Address - Country:US
Mailing Address - Phone:928-729-8000
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF ROUTE N12 AND N7
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27766208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN370022568Medicare PIN
TN113180OtherBETTER HEALTH PLANS
TN4049790OtherBCBS
TN3880553Medicare PIN
TN5745430OtherAETNA
TN3880553Medicaid
TN113180OtherUNISON
TN11474OtherTLC
TN2286769OtherCIGNA
TNG36834Medicare UPIN