Provider Demographics
NPI:1417976283
Name:DOUGLAS, MARTIN K (OT)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:K
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5890
Mailing Address - Fax:740-446-5532
Practice Address - Street 1:313 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1263
Practice Address - Country:US
Practice Address - Phone:304-744-2300
Practice Address - Fax:304-744-5891
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV366224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1417976283OtherNPI
WV3810000217Medicaid
000000217244OtherANTHEM BCBS
WV3810000217Medicaid