Provider Demographics
NPI:1346638210
Name:RETHERFORD, MARTIN (DOM)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:RETHERFORD
Suffix:
Gender:M
Credentials:DOM
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 15386
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-0386
Mailing Address - Country:US
Mailing Address - Phone:505-433-7309
Mailing Address - Fax:
Practice Address - Street 1:10200 KEEPING DR NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4601
Practice Address - Country:US
Practice Address - Phone:909-223-9809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-31
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1154171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13439375Medicaid