Basic Information
| Provider Information | |||||||||
| NPI: | 1649288754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 896239 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282896239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039266820 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3799 12TH STREET EXTENSION | ||||||||
| Address2: | STE 105 | ||||||||
| City: | CAYCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039266820 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 7360 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 073609 | 05 | SC | MEDICAID |