Provider Demographics
NPI:1215409289
Name:MARTIN, PETER JD (BS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3312 RIDGECREST CIR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-7535
Mailing Address - Country:US
Mailing Address - Phone:405-397-6520
Mailing Address - Fax:
Practice Address - Street 1:805 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6610
Practice Address - Country:US
Practice Address - Phone:405-447-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-01
Last Update Date:2019-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200013070Medicaid