Provider Demographics
NPI:1083678023
Name:MINER, MARTIN M (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:M
Last Name:MINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 SUMMIT AVE
Mailing Address - Street 2:FAIN BLDING
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2853
Mailing Address - Country:US
Mailing Address - Phone:401-793-4636
Mailing Address - Fax:401-793-4639
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:FAIN BLDING
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-4636
Practice Address - Fax:401-793-4639
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RI6413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMM71802Medicaid
RI007060540Medicare PIN