Provider Demographics
NPI:1003032731
Name:MARTIN, EUGENE DALE (DC)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:DALE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:GENE
Other - Middle Name:DALE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:W3734 ROCK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LOYAL
Mailing Address - State:WI
Mailing Address - Zip Code:54446
Mailing Address - Country:US
Mailing Address - Phone:715-267-7890
Mailing Address - Fax:
Practice Address - Street 1:134 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:WI
Practice Address - Zip Code:54437-0214
Practice Address - Country:US
Practice Address - Phone:715-267-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2129111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38911700Medicaid