Provider Demographics
NPI:1972037950
Name:MARTIN, VIVIAN (PT)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT
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 370
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:OK
Mailing Address - Zip Code:74346-0370
Mailing Address - Country:US
Mailing Address - Phone:918-253-4511
Mailing Address - Fax:
Practice Address - Street 1:432 SOUTH 9TH
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:OK
Practice Address - Zip Code:74346
Practice Address - Country:US
Practice Address - Phone:918-253-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT1880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist