1881037018 NPI number — KYLE DENISON MARTIN D.O., MA, MPH

Table of content: KYLE DENISON MARTIN D.O., MA, MPH (NPI 1881037018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881037018 NPI number — KYLE DENISON MARTIN D.O., MA, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
KYLE
Provider Middle Name:
DENISON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O., MA, MPH
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:
1881037018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 WHIPPLE STREET, 3RD FLOOR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02908-3258
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-854-2504
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
593 EDDY ST
Provider Second Line Business Practice Location Address:
CLAVERICK 2
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-854-2504
Provider Business Practice Location Address Fax Number:
401-427-7795
Provider Enumeration Date:
04/08/2013

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: 207P00000X , with the licence number:  5101020571 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: DC00855 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DC00855 . This is a "RI LICENSE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".




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