Provider Demographics
NPI:1023067196
Name:POURKESALI, MARTIN M (DO)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:M
Last Name:POURKESALI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:28 OFFICE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137
Mailing Address - Country:US
Mailing Address - Phone:386-246-6289
Mailing Address - Fax:386-246-6389
Practice Address - Street 1:28 OFFICE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137
Practice Address - Country:US
Practice Address - Phone:386-246-6289
Practice Address - Fax:386-246-6389
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S8658207W00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL84276Medicare PIN
H24669Medicare UPIN