Provider Demographics
NPI:1639137516
Name:MARTIN, MIKE P (DPM)
Entity Type:Individual
Prefix:DR
First Name:MIKE
Middle Name:P
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-0151
Mailing Address - Country:US
Mailing Address - Phone:918-563-4239
Mailing Address - Fax:
Practice Address - Street 1:1 CHOCTAW WAY
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2022
Practice Address - Country:US
Practice Address - Phone:918-567-7019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT143213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1499419Medicaid
OKU95118Medicare UPIN