Provider Demographics
NPI:1043447899
Name:MARTIN, STEPHEN BROOKS (IDMT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BROOKS
Last Name:MARTIN
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4881 SUGAR MAPLE DR
Mailing Address - Street 2:88 MDOS
Mailing Address - City:WPAFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-257-0770
Mailing Address - Fax:
Practice Address - Street 1:4881 SUGAR MAPLE DR
Practice Address - Street 2:88 MDOS
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433
Practice Address - Country:US
Practice Address - Phone:937-257-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians