Provider Demographics
NPI:1225022106
Name:MARTIN, RICHARD ALLAN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLAN
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 1:150 SOUTH MOUNT AUBURN ROAD
Mailing Address - Street 2:SUITE 420
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703
Mailing Address - Country:US
Mailing Address - Phone:573-335-4448
Mailing Address - Fax:573-335-4466
Practice Address - Street 1:150 SOUTH MOUNT AUBURN ROAD
Practice Address - Street 2:SUITE 420
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703
Practice Address - Country:US
Practice Address - Phone:573-335-4448
Practice Address - Fax:573-335-4466
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8494207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO27666OtherBLUE CROSS
MO200764918Medicaid
211029OtherHEALTHLINK
MO27666OtherBLUE CROSS
MO001011004Medicare ID - Type Unspecified