Provider Demographics
NPI:1336105873
Name:MARTIN, BRIAN (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 MAPLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1976
Mailing Address - Country:US
Mailing Address - Phone:573-756-7779
Mailing Address - Fax:888-849-3965
Practice Address - Street 1:606 MAPLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1976
Practice Address - Country:US
Practice Address - Phone:573-756-7779
Practice Address - Fax:888-849-3965
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005263213ES0103X
MO2004019390213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOV06081Medicare UPIN
MO258641160Medicare PIN