Provider Demographics
NPI:1366467706
Name:SKINNER, MARTIN D (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:D
Last Name:SKINNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13994
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-0994
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:545 NE 47TH AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2238
Practice Address - Country:US
Practice Address - Phone:503-215-9700
Practice Address - Fax:503-215-9701
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD16976207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR110191669OtherRR MEDICARE
OR110191669OtherRR MEDICARE