1942415369 NPI number — MICHAEL MARTUCCI MD

Table of content: MICHAEL MARTUCCI MD (NPI 1942415369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942415369 NPI number — MICHAEL MARTUCCI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTUCCI
Provider First Name:
MICHAEL
Provider Middle Name:
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:
1942415369
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603725
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-3725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-575-2625
Provider Business Mailing Address Fax Number:
828-350-2174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 E HARMONY RD UNIT 290
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80528-3402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-221-2370
Provider Business Practice Location Address Fax Number:
970-221-9654
Provider Enumeration Date:
05/11/2007

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: 207K00000X , with the licence number:  9767A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207K00000X , with the licence number: DR.0048242 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10027065300 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 30928371 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 135469800 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 391620ZMHC . This is a "MEDICARE PTAN" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: W27146 . This is a "MEDICARE PTAN" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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