Provider Demographics
NPI:1952301665
Name:ABBOTT, MARTIN K (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:K
Last Name:ABBOTT
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:PO BOX 1663
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-0031
Mailing Address - Country:US
Mailing Address - Phone:509-529-1284
Mailing Address - Fax:
Practice Address - Street 1:1277 WOODWARD CANYON RD
Practice Address - Street 2:
Practice Address - City:TOUCHET
Practice Address - State:WA
Practice Address - Zip Code:99360-9709
Practice Address - Country:US
Practice Address - Phone:509-529-1284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033653207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR080739Medicaid
WA1098367Medicaid
WA050047616OtherRAILROAD MEDICARE
WAG115000889Medicare PIN
WA1098367Medicaid