Provider Demographics
NPI:1497759450
Name:MARTIN, THOMAS MICHAEL (RPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MICHAEL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-2807
Mailing Address - Country:US
Mailing Address - Phone:304-842-3137
Mailing Address - Fax:304-842-3138
Practice Address - Street 1:39 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-842-3137
Practice Address - Fax:304-842-3138
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000437174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV01071873100OtherWORKERS' COMPENSATION
WV33664OtherHEALTH ASSURANCE
WV398792OtherOPTIMUM CHOICE
WV1382862OtherUMWA
WV5235074OtherAETNA
WV7301125000Medicaid
WVWV51916BOtherHEALTH PLAN
WVMA0546715Medicare ID - Type Unspecified