Basic Information
| Provider Information | |||||||||
| NPI: | 1285173591 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1514 VERNON RD | ||||||||
| Address2: | |||||||||
| City: | LAGRANGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302404131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068122369 | ||||||||
| FaxNumber: | 7068453194 | ||||||||
| Practice Location | |||||||||
| Address1: | 5001 HARDY ST | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012963963 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2017 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 86029 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | MS | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 86029 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.