Provider Demographics
NPI:1881216935
Name:MARTIN, BARRY DEAN
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:DEAN
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 1:2230 W SUNSET ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5980
Mailing Address - Country:US
Mailing Address - Phone:417-573-2103
Mailing Address - Fax:
Practice Address - Street 1:2230 W SUNSET ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5980
Practice Address - Country:US
Practice Address - Phone:417-573-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist