Provider Demographics
NPI:1629664065
Name:MARTIN, STUART A
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 COUNTY ROAD 504
Mailing Address - Street 2:
Mailing Address - City:DESDEMONA
Mailing Address - State:TX
Mailing Address - Zip Code:76445-1609
Mailing Address - Country:US
Mailing Address - Phone:210-907-3310
Mailing Address - Fax:
Practice Address - Street 1:309 COUNTY ROAD 504
Practice Address - Street 2:
Practice Address - City:DESDEMONA
Practice Address - State:TX
Practice Address - Zip Code:76445-1609
Practice Address - Country:US
Practice Address - Phone:210-907-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-20
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty