Provider Demographics
NPI:1619177375
Name:MARTIN, PHIL W (DC)
Entity Type:Individual
Prefix:DR
First Name:PHIL
Middle Name:W
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 1:1426 E. ELM STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802
Mailing Address - Country:US
Mailing Address - Phone:417-862-6127
Mailing Address - Fax:417-862-6127
Practice Address - Street 1:1426 E ELM ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-3308
Practice Address - Country:US
Practice Address - Phone:417-862-6127
Practice Address - Fax:417-862-6127
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO04513111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor