Basic Information
| Provider Information | |||||||||
| NPI: | 1356381834 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | SUSAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 CAPITAL OAKS DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504317021 | ||||||||
| FaxNumber: | 8504316975 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 CAPITAL OAKS DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504314041 | ||||||||
| FaxNumber: | 8504314471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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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 | 207SG0201X | ME43734 | FL | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) | 208800000X | ME43734 | FL | N | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 278957400 | 05 | FL | MEDICAID | 102212446A | 05 | GA | MEDICAID | 102212446A | 01 | GA | MEDICAID | OTHER |