Provider Demographics
NPI:1629053236
Name:MARTIN, NICHOLAUS BRUCE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAUS
Middle Name:BRUCE
Last Name:MARTIN
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 1:120 W FINE AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3016
Mailing Address - Country:US
Mailing Address - Phone:928-773-9695
Mailing Address - Fax:928-773-0208
Practice Address - Street 1:120 W FINE AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3016
Practice Address - Country:US
Practice Address - Phone:928-773-9695
Practice Address - Fax:928-773-0208
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18430208D00000X
CO40573208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ133669Medicare UPIN
AZZ120963Medicare PIN
WDB7Q01Medicare ID - Type Unspecified
AZZ121095Medicare UPIN
F10848Medicare UPIN