NPIMap

Organization Active NPI

Wallace F. Martin, M.D.

  • Surgery Physician
  • Lawrenceville, GA
National Provider Identifier
1124225065
Registry record updated Sep 1, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgery PhysicianTaxonomy code 208600000X
License
026153 Issued in GA
Legal business name
WALLACE F. MARTIN, M.D.
Practice address
631 Professional Dr
Suite 300
Lawrenceville, GA 30046-3371
Phone
(770) 962-9977
Fax
(770) 339-9804
NPI assigned
Jul 2, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 1, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Wallace Ford Martin, M.D.
Title
Owner
Phone
(770) 962-9977

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Surgery PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208600000X 026153 GA Primary

Addresses

Primary practice location

631 Professional Dr
Suite 300
Lawrenceville, GA 30046-3371

Mailing address

631 Professional Drive
Suite 300
Lawrenceville, GA 30046-3371
Phone (770) 962-9977

Other identifiers 2

IdentifierTypeStateIssuer
GRP1797OtherGAMEDICARE GROUP#
00301914AMedicaidGA

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1183334400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1283299200000",
    "number": "1124225065",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "631 PROFESSIONAL DRIVE",
            "address_2": "SUITE 300",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300463371",
            "telephone_number": "770-962-9977",
            "fax_number": "770-339-9804"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "631 PROFESSIONAL DR",
            "address_2": "SUITE 300",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300463371",
            "telephone_number": "770-962-9977",
            "fax_number": "770-339-9804"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALLACE F. MARTIN, M.D.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-02",
        "last_updated": "2010-09-01",
        "status": "A",
        "authorized_official_last_name": "MARTIN",
        "authorized_official_first_name": "WALLACE",
        "authorized_official_middle_name": "FORD",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "770-962-9977",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Surgery",
            "state": "GA",
            "license": "026153",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP#",
            "identifier": "GRP1797",
            "state": "GA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00301914A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lawrenceville, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.