Provider Demographics
NPI:1689758195
Name:MARTONICK, GREGORY JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JOSEPH
Last Name:MARTONICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1793
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0351
Mailing Address - Country:US
Mailing Address - Phone:509-525-4840
Mailing Address - Fax:509-529-7355
Practice Address - Street 1:320 W WILLOW ST STE 6
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2922
Practice Address - Country:US
Practice Address - Phone:509-525-4840
Practice Address - Fax:509-529-7355
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA252-09-0018690207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1300342Medicaid
WA0063736OtherL & I NUMBER
WA1300244Medicare ID - Type Unspecified
WAA09409Medicare UPIN