Provider Demographics
NPI:1922053057
Name:MARTZKE, GARY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LYNN
Last Name:MARTZKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-530-2177
Mailing Address - Fax:
Practice Address - Street 1:3071 CHAMINADE CT SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2593
Practice Address - Country:US
Practice Address - Phone:616-530-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044764207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4228280Medicaid
MI4283370Medicaid
MI4554956Medicaid
MI4228261Medicaid
MI4592509Medicaid
MIM02830094Medicare ID - Type Unspecified
MI4228261Medicaid