Provider Demographics
NPI:1578911590
Name:GLAVES, MARTIN (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:GLAVES
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 4105
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4105
Mailing Address - Country:US
Mailing Address - Phone:866-907-1068
Mailing Address - Fax:425-917-9141
Practice Address - Street 1:17025 SNOWMOBILE LN STE 102
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7044
Practice Address - Country:US
Practice Address - Phone:907-694-9593
Practice Address - Fax:907-694-9585
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK109945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1647440Medicaid