1417066259 NPI number — W PATRICK MARTIN MD PA

Table of content: (NPI 1417066259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417066259 NPI number — W PATRICK MARTIN MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
W PATRICK MARTIN MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417066259
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1339 EAST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAHAM
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76450-4228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-521-5500
Provider Business Mailing Address Fax Number:
940-521-5511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1339 EAST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAHAM
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76450-4228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-521-5500
Provider Business Practice Location Address Fax Number:
940-521-5511
Provider Enumeration Date:
08/29/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
W
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
940-521-5500

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  K7815 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 154580801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: DG3960 . This is a "RAILROAD PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0041PY . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".