Provider Demographics
NPI:1619998952
Name:HENDRICKSON, MARTIN (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:HENDRICKSON
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 1:717 CANTON RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44312-2606
Mailing Address - Country:US
Mailing Address - Phone:330-733-4031
Mailing Address - Fax:330-733-7887
Practice Address - Street 1:717 CANTON RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44312-2606
Practice Address - Country:US
Practice Address - Phone:330-733-4031
Practice Address - Fax:330-733-7887
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-006007207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2551671OtherPARTNERS PHYSICIAN GROUP MEDICAID GROUP #
OH0166681Medicaid
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH9338635OtherPARTNERS PHYSICIAN GROUP MEDICARE #
OHG57939Medicare UPIN
OHH226020Medicare PIN