1609826023 NPI number — EMMANUEL M MARTAKIS MD

Table of content: EMMANUEL M MARTAKIS MD (NPI 1609826023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609826023 NPI number — EMMANUEL M MARTAKIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTAKIS
Provider First Name:
EMMANUEL
Provider Middle Name:
M
Provider Name Prefix Text:
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:
1609826023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 987
Provider Second Line Business Mailing Address:
21 ORCHARD STREET
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10940-5004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-343-7614
Provider Business Mailing Address Fax Number:
845-343-5390

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 HAMMOND STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT JERVIS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12771-2607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-858-2854
Provider Business Practice Location Address Fax Number:
845-343-5390
Provider Enumeration Date:
05/10/2006

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: 208000000X , with the licence number:  238463 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: MD429082 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1018494050004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02719937 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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