Basic Information
| Provider Information | |||||||||
| NPI: | 1215917018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUNNINGHAM | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2405 SE 17TH ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344719192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526902171 | ||||||||
| FaxNumber: | 3526906954 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 NE 25TH AVE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344705667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526222221 | ||||||||
| FaxNumber: | 3526224193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME34335 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00896710 | 01 | FL | RR MEDICARE | OTHER | 273687000 | 05 | FL | MEDICAID | 02035 | 01 | FL | BCBS | OTHER |