Provider Demographics
NPI:1467454975
Name:HACKETT, MARTHA E (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:HACKETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7590 AUBURN ROAD, SUITE 014
Mailing Address - Street 2:ATTN: MED STAFF
Mailing Address - City:CONCORD TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9176
Mailing Address - Country:US
Mailing Address - Phone:440-354-1899
Mailing Address - Fax:440-354-1845
Practice Address - Street 1:8300 TYLER BLVD STE 300
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4251
Practice Address - Country:US
Practice Address - Phone:440-205-1529
Practice Address - Fax:440-205-0840
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 043939-H207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0484042Medicaid
C03749Medicare UPIN
HA0509755Medicare ID - Type Unspecified