1003121278 NPI number — DR. JEREMY DAVID MARTINSEN DPT

Table of content: DR. JEREMY DAVID MARTINSEN DPT (NPI 1003121278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003121278 NPI number — DR. JEREMY DAVID MARTINSEN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTINSEN
Provider First Name:
JEREMY
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1003121278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3115 ROUTE 38
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
MOUNT LAUREL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08054-9725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-273-8080
Provider Business Mailing Address Fax Number:
856-273-0633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3115 ROUTE 38
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
MOUNT LAUREL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08054-9725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-273-8080
Provider Business Practice Location Address Fax Number:
856-273-0633
Provider Enumeration Date:
08/12/2010

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: 225100000X , with the licence number:  40QA01365700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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