Provider Demographics
NPI:1104181817
Name:MARTIN, MICHAEL LLOYD (CP,LP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LLOYD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:CP,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 N CLASSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-5031
Mailing Address - Country:US
Mailing Address - Phone:405-525-4000
Mailing Address - Fax:405-530-3670
Practice Address - Street 1:4301 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-5031
Practice Address - Country:US
Practice Address - Phone:405-525-4000
Practice Address - Fax:405-530-3670
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLP30224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKLP30OtherOKLAHOMA BOARD OF MEDICAL LICENSURE & SUPERVISION FOR ORTHOTICS & PROSTHETICS
CP2599OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS & PROSTHETICS