Provider Demographics
NPI:1982650768
Name:MARTIN, AMY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2181 E COCONINO DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-6132
Mailing Address - Country:US
Mailing Address - Phone:480-262-8663
Mailing Address - Fax:480-264-6049
Practice Address - Street 1:2181 E COCONINO DR
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-6132
Practice Address - Country:US
Practice Address - Phone:480-262-8663
Practice Address - Fax:480-264-6049
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT11426208600000X
AZ44731208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1982650768Medicaid
AZ625707Medicaid
MT0000097536OtherBLUE CROSS BLUE SHIELD MT
MT611532402OtherDEPARTMENT OF LABOR
MT1982650768OtherMBCHP
AZZ144968Medicare PIN
MT000085424Medicare UPIN
AZZ144967Medicare PIN
MT0000097536OtherBLUE CROSS BLUE SHIELD MT
MT011000552Medicare PIN