Provider Demographics
NPI:1083641237
Name:MARTIN, JOHN BLANCHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BLANCHARD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:1215 N BEAVER ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3126
Practice Address - Country:US
Practice Address - Phone:928-773-2200
Practice Address - Fax:928-773-2300
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4397103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1716-057OtherWI LICENSE NUMBER
AZ810762Medicaid
AZZ184176Medicare PIN
AZ810762Medicaid