Provider Demographics
NPI:1699001693
Name:MARTIN, LARRY GENE (AUD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:GENE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:983 NW SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-2111
Mailing Address - Country:US
Mailing Address - Phone:541-753-2068
Mailing Address - Fax:541-753-5392
Practice Address - Street 1:983 NW SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-2111
Practice Address - Country:US
Practice Address - Phone:541-753-2068
Practice Address - Fax:541-753-5392
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20896231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist