1942329636 NPI number — VINCE RUSSELL MARTIN P.A.

Table of content: VINCE RUSSELL MARTIN P.A. (NPI 1942329636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942329636 NPI number — VINCE RUSSELL MARTIN P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
VINCE
Provider Middle Name:
RUSSELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
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:
1942329636
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 W CHEROKEE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALLISAW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74955-4216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-775-0007
Provider Business Mailing Address Fax Number:
918-775-8910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 W CHEROKEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALLISAW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74955-4216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-775-0007
Provider Business Practice Location Address Fax Number:
918-775-8910
Provider Enumeration Date:
03/27/2007

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: 363AM0700X , with the licence number:  1514 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1514 . This is a "OKLAHOMA LICENSE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 34366 . This is a "OK BUR OF NARCOTICS & DD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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