Provider Demographics
NPI:1710378112
Name:MARTIN, MICHAEL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26005 E 107TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-3944
Mailing Address - Country:US
Mailing Address - Phone:918-946-7136
Mailing Address - Fax:
Practice Address - Street 1:26005 E 107TH ST S
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-3944
Practice Address - Country:US
Practice Address - Phone:918-946-7136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-07
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist