1093774127 NPI number — DAVID R MARTIN M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093774127 NPI number — DAVID R MARTIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
DAVID
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1093774127
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 WILLIAM D TATE AVE
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
GRAPEVINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76051-8755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-488-6812
Provider Business Mailing Address Fax Number:
817-251-1303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 WESTPARK WAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
EULESS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76040-3972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-283-5166
Provider Business Practice Location Address Fax Number:
817-283-5176
Provider Enumeration Date:
03/18/2006

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: 207RN0300X , with the licence number:  L3389 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7617368 . This is a "AETNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 150569507 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 207735 . This is a "PACIFICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 150569509 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8CE650 . This is a "BCBS TX" identifier . This identifiers is of the category "OTHER".
  • Identifier: P000789478 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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