Provider Demographics
NPI:1609926211
Name:BYDALEK, MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:BYDALEK
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 1:2819 DENNY AVENUE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2819 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581
Practice Address - Country:US
Practice Address - Phone:228-762-3466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10633207Q00000X
MSMS10633207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
930026514OtherRAILROAD MEDICARE
MS00015597Medicaid
MS386693YKC0OtherMEDICARE
646000515OtherTRICARE
AL008605220Medicaid
646000515OtherBLUE CROSS OF MS
AL008605220Medicaid