Provider Demographics
NPI:1144763004
Name:MARTIN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:3041 S CHARLTON PARK RD
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-8806
Mailing Address - Country:US
Mailing Address - Phone:269-945-0956
Mailing Address - Fax:
Practice Address - Street 1:3041 S CHARLTON PARK RD
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-8806
Practice Address - Country:US
Practice Address - Phone:269-945-0956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM635585161310247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other