Provider Demographics
NPI:1073171716
Name:MARTIN, PETER (DPT)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4742 LIBERTY RD S # 2032
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5037
Mailing Address - Country:US
Mailing Address - Phone:503-877-4974
Mailing Address - Fax:503-822-0328
Practice Address - Street 1:4910 TURNER RD SE STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-9627
Practice Address - Country:US
Practice Address - Phone:503-877-4974
Practice Address - Fax:503-822-0328
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2024-03-22
Deactivation Date:2023-05-23
Deactivation Code:
Reactivation Date:2023-06-12
Provider Licenses
StateLicense IDTaxonomies
WYPT-1891225100000X
OR63233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPENDINGMedicaid