Provider Demographics
NPI:1659351682
Name:MARTIN, SHANE L (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20401 N 73RD ST STE 160
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-4149
Mailing Address - Country:US
Mailing Address - Phone:623-208-7979
Mailing Address - Fax:800-483-0729
Practice Address - Street 1:20401 N 73RD ST STE 160
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-4149
Practice Address - Country:US
Practice Address - Phone:623-208-7979
Practice Address - Fax:800-483-0729
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2023-01-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ34339207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ583819Medicaid
AZ3Z5706OtherHEALTHNET
AZ3Z5706OtherHEALTHNET
AZP00841990Medicare PIN