Provider Demographics
NPI:1639865009
Name:MARTIN, DWAINE ATHONY SR
Entity Type:Individual
Prefix:MR
First Name:DWAINE
Middle Name:ATHONY
Last Name:MARTIN
Suffix:SR
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 1:4440 E 131ST ST
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44105-6984
Mailing Address - Country:US
Mailing Address - Phone:216-240-9027
Mailing Address - Fax:
Practice Address - Street 1:4440 E 131ST ST
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44105-6984
Practice Address - Country:US
Practice Address - Phone:216-240-9027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRT708749343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)