Basic Information
| Provider Information | |||||||||
| NPI: | 1326026444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636930 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139815015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 825 W MARKET ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458052799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199965780 | ||||||||
| FaxNumber: | 4199965781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 12/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-042566 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000029134 | 01 | OH | ANTHEM | OTHER | 0396530 | 05 | OH | MEDICAID | 000000029133 | 01 | OH | ANTHEM | OTHER |