Provider Demographics
NPI:1821303207
Name:MALT, MARTIN (PT)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:MALT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VILLAGE SQ
Mailing Address - Street 2:SUITE A
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-1817
Mailing Address - Country:US
Mailing Address - Phone:314-551-6154
Mailing Address - Fax:314-551-6105
Practice Address - Street 1:1 VILLAGE SQ
Practice Address - Street 2:SUITE A
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1817
Practice Address - Country:US
Practice Address - Phone:314-551-6154
Practice Address - Fax:314-551-6105
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002027725174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist