Provider Demographics
NPI:1982674719
Name:MARTIN, EDWARD T (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:T
Last Name:MARTIN
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 1:9228 S MINGO RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5718
Mailing Address - Country:US
Mailing Address - Phone:918-592-0999
Mailing Address - Fax:918-878-2499
Practice Address - Street 1:9228 S MINGO RD
Practice Address - Street 2:SUITE 200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5718
Practice Address - Country:US
Practice Address - Phone:918-592-0999
Practice Address - Fax:918-878-2499
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20675174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100028120AMedicaid
OK060049596OtherMEDICARE RAILROAD
OKOK700124OtherMEDICARE PTAN
OKP00613404OtherMEDICARE RAILROAD
OK100028120AMedicaid