Provider Demographics
NPI:1225529688
Name:MARTIN, DAVID ANDREW
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANDREW
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 207
Mailing Address - Street 2:
Mailing Address - City:LA JARA
Mailing Address - State:CO
Mailing Address - Zip Code:81140-0207
Mailing Address - Country:US
Mailing Address - Phone:719-580-6947
Mailing Address - Fax:
Practice Address - Street 1:15310 CR T.37
Practice Address - Street 2:
Practice Address - City:LA JARA
Practice Address - State:CO
Practice Address - Zip Code:81140
Practice Address - Country:US
Practice Address - Phone:719-580-6947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor