Provider Demographics
NPI:1457480618
Name:INCLAN, MARTINA (MD)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:INCLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARTINA
Other - Middle Name:
Other - Last Name:KEELER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 109
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-2084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301084472208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4985551Medicaid
MI1922090554OtherGROUP NPI
MI1558407189OtherGROUP NPI
MI350D176310OtherBSBS