Provider Demographics
NPI:1316224058
Name:MARY WADE MARTIN MD PC
Entity Type:Organization
Organization Name:MARY WADE MARTIN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-936-0504
Mailing Address - Street 1:608 NW 9TH ST
Mailing Address - Street 2:SUITE 5010
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-1068
Mailing Address - Country:US
Mailing Address - Phone:405-272-7026
Mailing Address - Fax:405-272-7027
Practice Address - Street 1:608 NW 9TH ST
Practice Address - Street 2:SUITE 5010
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-1068
Practice Address - Country:US
Practice Address - Phone:405-272-7026
Practice Address - Fax:405-272-7027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23664207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200016330AMedicaid
OKG07640Medicare UPIN