Provider Demographics
NPI:1972580710
Name:MARTY, DAVID R (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:MARTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-556-7708
Mailing Address - Fax:573-893-8061
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-556-7708
Practice Address - Fax:573-893-8061
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7197207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5350OtherBCBS
MOCP9089OtherRR GROUP
MO040007612OtherMEDICARE RAILROAD
MO990001391OtherMCR GROUP
MO172463OtherHEALTHLINK
MO201039930Medicaid
MO172463OtherHEALTHLINK
A11448Medicare UPIN