1003855743 NPI number — DR. LELAND KARL MARTIN PHD

Table of content: DR. LELAND KARL MARTIN PHD (NPI 1003855743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003855743 NPI number — DR. LELAND KARL MARTIN PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
LELAND
Provider Middle Name:
KARL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
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:
1003855743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2434 COMMERCE BLVD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUND
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55364-1480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-595-0562
Provider Business Mailing Address Fax Number:
952-595-0564

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2434 COMMERCE BLVD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUND
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55364-1480
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-595-0562
Provider Business Practice Location Address Fax Number:
952-595-0564
Provider Enumeration Date:
06/06/2006

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: 103TC0700X , with the licence number:  LP3095 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 783725900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP27418 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6129689 . This is a "UNITED BEHAVIORAL HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 169220 . This is a "COMPSYCH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5H813MA . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 109951 . This is a "BEHAVIORAL HEALTH CARE PR" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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