Provider Demographics
NPI:1720399280
Name:LAFOLLETTE, MARTIN J (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:J
Last Name:LAFOLLETTE
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 1:2303 N 390 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1733
Mailing Address - Country:US
Mailing Address - Phone:800-997-6196
Mailing Address - Fax:
Practice Address - Street 1:10180 W HAPPY VALLEY RD STE 100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-1389
Practice Address - Country:US
Practice Address - Phone:623-561-3000
Practice Address - Fax:623-561-3009
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10776207Q00000X
IDOC-0010207Q00000X
MTMED-PHYS-LIC-61129207Q00000X
MS25516207Q00000X
WAOP60826527207Q00000X
KS05-40628207Q00000X
NVCL0017207Q00000X
MN63228207Q00000X
IADO-05136207Q00000X
UT10663123-1204207Q00000X
NE1772207Q00000X
ALDO.1788207Q00000X
COCDR.0000063207Q00000X
WI13-321207Q00000X
AZ006138207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine