Provider Demographics
NPI:1710042023
Name:MARTIN, WILLIAM JASON (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JASON
Last Name:MARTIN
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 1:406 ELK CIR
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-8202
Mailing Address - Country:US
Mailing Address - Phone:312-371-8570
Mailing Address - Fax:
Practice Address - Street 1:406 ELK CIR
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-8202
Practice Address - Country:US
Practice Address - Phone:312-371-8570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45810208200000X
NY239972208200000X
IL208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery