Provider Demographics
NPI:1366547002
Name:MARTIN, OLA JENELLE (MD)
Entity type:Individual
Prefix:
First Name:OLA
Middle Name:JENELLE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENELLE
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1650 PINETREE PASS LN SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047
Mailing Address - Country:US
Mailing Address - Phone:770-638-1960
Mailing Address - Fax:770-638-1961
Practice Address - Street 1:3469 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 103
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5888
Practice Address - Country:US
Practice Address - Phone:770-638-1960
Practice Address - Fax:770-638-1961
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0346602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00599915EMedicaid
GA26BDFHMMedicare ID - Type Unspecified
GA00599915EMedicaid