Provider Demographics
NPI:1609826023
Name:MARTAKIS, EMMANUEL M (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:M
Last Name:MARTAKIS
Suffix:
Gender:M
Credentials:MD
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 987
Mailing Address - Street 2:21 ORCHARD STREET
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-5004
Mailing Address - Country:US
Mailing Address - Phone:845-343-7614
Mailing Address - Fax:845-343-5390
Practice Address - Street 1:140 HAMMOND STREET
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2607
Practice Address - Country:US
Practice Address - Phone:845-858-2854
Practice Address - Fax:845-343-5390
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238463208000000X
PAMD429082208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1018494050004Medicaid
NY02719937Medicaid
PA1018494050004Medicaid