Provider Demographics
NPI:1093708877
Name:PASSEN, MARTIN I (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:I
Last Name:PASSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 W JOPPA RD
Mailing Address - Street 2:SUITE 315
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4624
Mailing Address - Country:US
Mailing Address - Phone:410-337-8446
Mailing Address - Fax:410-337-5580
Practice Address - Street 1:2360 W JOPPA RD
Practice Address - Street 2:SUITE 315
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4624
Practice Address - Country:US
Practice Address - Phone:410-337-8446
Practice Address - Fax:410-337-5580
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0042561207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKP27916VMedicare ID - Type Unspecified
MDF91112Medicare UPIN