Provider Demographics
NPI:1124001060
Name:MARTIN, JOHN D
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5718
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-5718
Mailing Address - Country:US
Mailing Address - Phone:406-756-0134
Mailing Address - Fax:406-309-2579
Practice Address - Street 1:3854 VILLAGE SEVEN RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917
Practice Address - Country:US
Practice Address - Phone:719-574-8761
Practice Address - Fax:719-574-8236
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0001380225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO75733331Medicaid
COC530788Medicare PIN
P89000Medicare UPIN