Provider Demographics
NPI:1477517118
Name:MARTY, THEODORE S III (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:S
Last Name:MARTY
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 SPRINGFIELD PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-1437
Mailing Address - Country:US
Mailing Address - Phone:513-821-6500
Mailing Address - Fax:513-821-4333
Practice Address - Street 1:1507 SPRINGFIELD PIKE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-1437
Practice Address - Country:US
Practice Address - Phone:513-821-6500
Practice Address - Fax:513-821-4333
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057786M207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0729831Medicaid
KY64939564Medicaid
D97988Medicare UPIN
KY64939564Medicaid
OH110157368Medicare PIN