Provider Demographics
NPI:1689615973
Name:MARTIN, MARK LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEE
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 1:350 E SARNIA ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3803
Mailing Address - Country:US
Mailing Address - Phone:507-454-0646
Mailing Address - Fax:507-452-1446
Practice Address - Street 1:350 E SARNIA ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3803
Practice Address - Country:US
Practice Address - Phone:507-454-0646
Practice Address - Fax:507-452-1446
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31429204D00000X, 207Q00000X, 208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3M316MAOtherBLUE CROSS/BLUE SHIELD
MN826787100Medicaid
MN826787100Medicaid
MN3M316MAOtherBLUE CROSS/BLUE SHIELD