Basic Information
| Provider Information | |||||||||
| NPI: | 1487651386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | WALLACE | ||||||||
| MiddleName: | FORD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 631 PROFESSIONAL DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300463371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709629977 | ||||||||
| FaxNumber: | 7703399804 | ||||||||
| Practice Location | |||||||||
| Address1: | 631 PROFESSIONAL DRIVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300463371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709629977 | ||||||||
| FaxNumber: | 7703399804 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 09/01/2010 | ||||||||
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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 | 208600000X | 026153 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | GRP1797 | 01 | GA | MEDICARE GROUP NUMBER | OTHER | 00301914A | 05 | GA | MEDICAID |