Provider Demographics
NPI:1801059332
Name:MARTIN, CRYSTAL DENISE (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:DENISE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:1401 HARRODSBURG RD STE B160
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1726
Practice Address - Country:US
Practice Address - Phone:859-276-4486
Practice Address - Fax:859-277-9164
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD46507207Q00000X
KY42964207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4278615OtherBCBS
TN1520403Medicaid
KY7100157060Medicaid
KY7100157060Medicaid