Provider Demographics
NPI:1801393913
Name:MARTIN, NICHOLAS ALLEN (DO)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALLEN
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 1:301 NORTH FIRST ST (BLDG 46)
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73523-5047
Mailing Address - Country:US
Mailing Address - Phone:580-481-5419
Mailing Address - Fax:
Practice Address - Street 1:301 NORTH FIRST ST (BLDG 46)
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73523-5047
Practice Address - Country:US
Practice Address - Phone:580-481-5419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072843207Q00000X
MO2020016504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine