Provider Demographics
NPI:1093261208
Name:MARTIN, PEYTON
Entity Type:Individual
Prefix:
First Name:PEYTON
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1589
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1589
Mailing Address - Country:US
Mailing Address - Phone:501-315-3344
Mailing Address - Fax:
Practice Address - Street 1:105 HWY 9
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:AR
Practice Address - Zip Code:72656-0096
Practice Address - Country:US
Practice Address - Phone:501-315-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116374726Medicaid
AR5B266Medicare PIN