Provider Demographics
NPI:1639302623
Name:MARTIN, JEFFREY (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:MARTIN
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 1:225000 HUMMINGBIRD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-2950
Mailing Address - Country:US
Mailing Address - Phone:715-359-6442
Mailing Address - Fax:715-393-0390
Practice Address - Street 1:225000 HUMMINGBIRD RD STE 100
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2950
Practice Address - Country:US
Practice Address - Phone:715-359-6442
Practice Address - Fax:715-393-0390
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT013120207X00000X
WI61724-21207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400156212Medicare PIN