1649303694 NPI number — DR. ERICK G MARTELL MD

Table of content: DR. ERICK G MARTELL MD (NPI 1649303694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649303694 NPI number — DR. ERICK G MARTELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTELL
Provider First Name:
ERICK
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1649303694
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 73720
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRBANKS
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99707-3720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-761-1934
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 LATHROP ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-5937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-459-3586
Provider Business Practice Location Address Fax Number:
907-374-7770
Provider Enumeration Date:
03/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  11981 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208200000X , with the licence number: 168881 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1720992 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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