Provider Demographics
NPI:1760429054
Name:MARTIN, DAVID STUART (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:STUART
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 1:14603 BIG TIMBER LANE
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017
Mailing Address - Country:US
Mailing Address - Phone:636-532-9294
Mailing Address - Fax:405-948-6507
Practice Address - Street 1:915 NORTH GRAND BOULEVARD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106
Practice Address - Country:US
Practice Address - Phone:636-532-9294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360520822085R0202X
MOR61462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1357740OtherBCBS OF TN
TN1357740OtherBCBS OF TN
ILP00057229Medicare ID - Type UnspecifiedRR
ILK00494Medicare ID - Type Unspecified