Provider Demographics
NPI:1477668606
Name:MARTIN, NICOLAS CLAY (DPM)
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:CLAY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12639 OLD TESSON RD STE 115
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:314-849-4423
Practice Address - Street 1:12639 OLD TESSON RD STE 115
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-849-0311
Practice Address - Fax:314-849-4423
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005025463213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00457779OtherRAILROAD MEDICARE
MO304056609Medicaid
MO304056609Medicaid
MOV11321Medicare UPIN