Provider Demographics
NPI:1104867621
Name:MARTIN, WAYNE ROBERT (MD)
Entity Type:Individual
Prefix:PROF
First Name:WAYNE
Middle Name:ROBERT
Last Name:MARTIN
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 1:1606 N PANORAMA WAY
Mailing Address - Street 2:
Mailing Address - City:COCHISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85606-8685
Mailing Address - Country:US
Mailing Address - Phone:701-880-0826
Mailing Address - Fax:
Practice Address - Street 1:1606 N PANORAMA WAY
Practice Address - Street 2:
Practice Address - City:COCHISE
Practice Address - State:AZ
Practice Address - Zip Code:85606-8685
Practice Address - Country:US
Practice Address - Phone:701-880-0826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42227207Q00000X
MT7466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8V4761OtherBCBS
C80779Medicare UPIN
TX8V4761OtherBCBS
TX8J7433Medicare PIN