Basic Information
| Provider Information | |||||||||
| NPI: | 1285671735 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRESHON | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043439800 | ||||||||
| FaxNumber: | 7043472011 | ||||||||
| Practice Location | |||||||||
| Address1: | 1640 E ROOSEVELT BLVD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281124017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042260599 | ||||||||
| FaxNumber: | 7042260599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 34065 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 19297 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 5031B | 01 | NC | BCBS | OTHER | P00612427 | 01 | NC | RR MEDICARE | OTHER | P00728483 | 01 | NC | RR MEDICARE SANGER | OTHER | N34065 | 05 | SC | MEDICAID | 895031B | 05 | NC | MEDICAID |