Provider Demographics
NPI:1780680520
Name:REILLY, MARTIN T (DO)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:T
Last Name:REILLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:M
Other - Middle Name:TODD
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:DEPT 960315
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0315
Mailing Address - Country:US
Mailing Address - Phone:580-548-1367
Mailing Address - Fax:580-548-1583
Practice Address - Street 1:401 E OKLAHOMA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5800
Practice Address - Country:US
Practice Address - Phone:580-242-5700
Practice Address - Fax:580-242-5712
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-05-30
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
OK4135207X00000X, 207XS0114X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200025140AMedicaid
OKP00142429Medicare PIN
OK200025140AMedicaid
OK246727102Medicare PIN
OK249418201Medicare PIN