Provider Demographics
NPI:1477563740
Name:MARTZ, MICHAEL DAVID (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:MARTZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-981-5015
Mailing Address - Fax:
Practice Address - Street 1:825 W MARKET ST
Practice Address - Street 2:SUITE 205
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2799
Practice Address - Country:US
Practice Address - Phone:419-996-5780
Practice Address - Fax:419-996-5781
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.008817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
11648024OtherCAQH
OH2677965Medicaid
OH34.008817OtherMEDICAL LICENSE
OH2677965Medicaid