Provider Demographics
NPI:1659351781
Name:FAITAK, MARTIN THOMAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:THOMAS
Last Name:FAITAK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N EAST AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-5225
Mailing Address - Country:US
Mailing Address - Phone:479-442-0763
Mailing Address - Fax:479-442-5587
Practice Address - Street 1:204 N EAST AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5225
Practice Address - Country:US
Practice Address - Phone:479-442-0763
Practice Address - Fax:479-442-5587
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR88-12P103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56390OtherBLUE CROSS BLUE SHIELD ID
AR56390Medicare PIN