Provider Demographics
NPI:1851040711
Name:MARTIN, ZACHARY CARTER
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:CARTER
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4535 AQUEDUCT LN UNIT 304
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-2081
Mailing Address - Country:US
Mailing Address - Phone:260-494-3281
Mailing Address - Fax:
Practice Address - Street 1:4535 AQUEDUCT LN UNIT 304
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-2081
Practice Address - Country:US
Practice Address - Phone:260-494-3281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-19
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN45021524A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program