Provider Demographics
NPI:1154475952
Name:MARTIN, KENNETH MICHAEL (PT MT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 LAKE VILLA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-6782
Mailing Address - Country:US
Mailing Address - Phone:504-888-7333
Mailing Address - Fax:504-888-1052
Practice Address - Street 1:2700 LAKE VILLA DR STE 100
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-6782
Practice Address - Country:US
Practice Address - Phone:504-888-7333
Practice Address - Fax:504-888-1052
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT01637225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
52918OtherBLUE CROSS
4B492C740Medicare PIN