Provider Demographics
NPI:1881037018
Name:MARTIN, KYLE DENISON (DO, MA, MPH)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DENISON
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO, MA, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 WHIPPLE STREET, 3RD FLOOR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-3258
Mailing Address - Country:US
Mailing Address - Phone:401-854-2504
Mailing Address - Fax:
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:CLAVERICK 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903
Practice Address - Country:US
Practice Address - Phone:401-854-2504
Practice Address - Fax:401-427-7795
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020571207P00000X
RIDC00855207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIDC00855OtherRI LICENSE