Provider Demographics
NPI:1558466995
Name:FAASSE, MARTIN JOHN (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:JOHN
Last Name:FAASSE
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:PO BOX 164
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49468
Mailing Address - Country:US
Mailing Address - Phone:616-534-3920
Mailing Address - Fax:616-534-0801
Practice Address - Street 1:3550 FAIRLANES SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418
Practice Address - Country:US
Practice Address - Phone:616-534-3920
Practice Address - Fax:616-534-0801
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMF000943213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1421894Medicaid
5415000OtherBCBS OF MICHIGAN
791480602Medicare ID - Type UnspecifiedRAILROAD
T34005Medicare UPIN
MI1421894Medicaid