Provider Demographics
NPI:1982656591
Name:TUBACH, MARTIN R (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:R
Last Name:TUBACH
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 1:6052 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-2739
Mailing Address - Country:US
Mailing Address - Phone:208-947-1947
Mailing Address - Fax:208-947-1945
Practice Address - Street 1:6052 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-2739
Practice Address - Country:US
Practice Address - Phone:208-947-1947
Practice Address - Fax:208-947-1945
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8065207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805751800Medicaid
G69001Medicare UPIN
ID805751800Medicaid