Provider Demographics
NPI:1942346473
Name:MARTIN, MICHAEL (OTRL)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1098 OLD STRONG HWY
Mailing Address - Street 2:
Mailing Address - City:STRONG
Mailing Address - State:AR
Mailing Address - Zip Code:71765-9560
Mailing Address - Country:US
Mailing Address - Phone:870-797-7802
Mailing Address - Fax:
Practice Address - Street 1:4450 SMACKOVER HWY
Practice Address - Street 2:
Practice Address - City:SMACKOVER
Practice Address - State:AR
Practice Address - Zip Code:71762-9533
Practice Address - Country:US
Practice Address - Phone:870-725-2497
Practice Address - Fax:870-725-2517
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2019-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1447225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y181OtherBLUE CROSS BLUE SHIELD
AR156989721Medicaid
AR5Y181OtherBLUE CROSS BLUE SHIELD