Basic Information
| Provider Information | |||||||||
| NPI: | 1174582126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1058 COLLEGE DR | ||||||||
| Address2: | |||||||||
| City: | NEW TOWN | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016274750 | ||||||||
| FaxNumber: | 7016273803 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 ASHVILLE AVE STE 10 | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275116669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198591136 | ||||||||
| FaxNumber: | 9198594240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2006 | ||||||||
| LastUpdateDate: | 06/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 30406 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 54142 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 8954142 | 05 | NC | MEDICAID | 7422261 | 01 | NC | AETNA | OTHER |