Provider Demographics
NPI:1558384289
Name:MARTIN, STACEY A (DPM)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 GRAHAM RD
Mailing Address - Street 2:
Mailing Address - City:CUYAHOGA FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44221-1302
Mailing Address - Country:US
Mailing Address - Phone:330-922-0114
Mailing Address - Fax:330-922-4202
Practice Address - Street 1:436 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-1302
Practice Address - Country:US
Practice Address - Phone:330-922-0114
Practice Address - Fax:330-922-4202
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003143213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34-1926954OtherTAX ID - GDS INC.
OH2201692Medicaid
OH480032643OtherRAILROAD MEDICARE
OH34-1926955OtherTAX ID - FALLS CHRONIC WO
OHMA4021782Medicare ID - Type UnspecifiedMEDICARE-GDS INC
OHGE9309771Medicare ID - Type UnspecifiedMEDICARE -GDS INC.
OH4021782Medicare PIN
OH2201692Medicaid
OH34-1926954OtherTAX ID - GDS INC.
OHU80443Medicare UPIN