Provider Demographics
NPI:1295439347
Name:MARTIN, MICHAEL WAYNE
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 BASKERVILLE DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2403
Mailing Address - Country:US
Mailing Address - Phone:240-460-7936
Mailing Address - Fax:
Practice Address - Street 1:3300 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-2408
Practice Address - Country:US
Practice Address - Phone:202-878-6626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-30
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker