Provider Demographics
NPI:1760570840
Name:MARTIN, GERALD MIKEL (DO)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:MIKEL
Last Name:MARTIN
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 1:350 S 40TH ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4915
Mailing Address - Country:US
Mailing Address - Phone:918-683-0753
Mailing Address - Fax:918-687-5251
Practice Address - Street 1:350 S 40TH ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4915
Practice Address - Country:US
Practice Address - Phone:918-683-0753
Practice Address - Fax:918-687-5251
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1990207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100255710AMedicaid
OK100255710AMedicaid