Provider Demographics
NPI:1942361423
Name:MARTIN, RANDAL DAVID (DPT)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:DAVID
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 372
Mailing Address - Street 2:
Mailing Address - City:HIGH ROLLS
Mailing Address - State:NM
Mailing Address - Zip Code:88325-0372
Mailing Address - Country:US
Mailing Address - Phone:505-443-8210
Mailing Address - Fax:
Practice Address - Street 1:1900 N WHITE SANDS BLVD
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6246
Practice Address - Country:US
Practice Address - Phone:505-437-3505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT2231225100000X
NM2231225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM79351Medicaid