Basic Information
| Provider Information | |||||||||
| NPI: | 1447211644 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | CANDIDU | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 732973 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753732973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177022450 | ||||||||
| FaxNumber: | 8177028445 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 S MAIN ST FL 4 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177021215 | ||||||||
| FaxNumber: | 8179276843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 05/22/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | K1249 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0603565-05 | 01 | TX | CSHCN | OTHER | 0603565-04 | 05 | TX | MEDICAID | 080177985 | 01 | TX | RR/MEDICARE | OTHER | 8B7330 | 01 | TX | BLUE SHIELD | OTHER |