Provider Demographics
NPI:1013397538
Name:STODDARD, MARTIN (PTA)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:STODDARD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13336 INDUSTRIAL RD STE 105
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1124
Mailing Address - Country:US
Mailing Address - Phone:402-330-3211
Mailing Address - Fax:402-330-5970
Practice Address - Street 1:13336 INDUSTRIAL RD STE 105
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1124
Practice Address - Country:US
Practice Address - Phone:402-330-3211
Practice Address - Fax:402-330-5970
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE847225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant