Provider Demographics
NPI:1073771622
Name:MARTIN, DAVID (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 LITTLE MEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:WARREN CENTER
Mailing Address - State:PA
Mailing Address - Zip Code:18851-7726
Mailing Address - Country:US
Mailing Address - Phone:570-395-0190
Mailing Address - Fax:
Practice Address - Street 1:1500 VESTAL PKWY E
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1830
Practice Address - Country:US
Practice Address - Phone:607-240-9120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT019277225100000X
NY62034406225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA127816PV9Medicare PIN