Provider Demographics
NPI:1114914538
Name:MARTIN, SCOTT A (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
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:N17W24100 RIVERWOOD DR STE 250
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1177
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:134 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3304
Practice Address - Country:US
Practice Address - Phone:920-261-6500
Practice Address - Fax:920-261-6107
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44871020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34510500Medicaid
WI68605Medicare ID - Type Unspecified
WI34510500Medicaid