Provider Demographics
NPI:1609904937
Name:MARTIN, SHAWN PATRICK (DC)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:PATRICK
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 EVERGREEN RD
Mailing Address - Street 2:STE 102
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1410
Mailing Address - Country:US
Mailing Address - Phone:502-489-8480
Mailing Address - Fax:
Practice Address - Street 1:138 EVERGREEN RD
Practice Address - Street 2:STE 102
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1410
Practice Address - Country:US
Practice Address - Phone:502-489-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3656111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000521890OtherANTHEM BC/BS
KY50018324OtherPASSPORT
KY7100042270Medicaid
KY00579001Medicare PIN
KY000000521890OtherANTHEM BC/BS