Provider Demographics
NPI:1114067329
Name:MARTIN, JOHN RUSSELL (DPH)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RUSSELL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HWYS JCT 270 & 56
Mailing Address - Street 2:WEWOKA INDIAN HEALTH CENTER
Mailing Address - City:WEWOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74884-1475
Mailing Address - Country:US
Mailing Address - Phone:405-257-7345
Mailing Address - Fax:405-257-3344
Practice Address - Street 1:HWYS JCT 270 & 56
Practice Address - Street 2:WEWOKA INDIAN HEALTH CENTER
Practice Address - City:WEWOKA
Practice Address - State:OK
Practice Address - Zip Code:74884-1475
Practice Address - Country:US
Practice Address - Phone:405-257-7345
Practice Address - Fax:405-257-3344
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10991183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist