Provider Demographics
NPI:1134169097
Name:MARTIN, CHARLES C (PT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12770 SOUTH FWY
Mailing Address - Street 2:SUITE 144
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-8447
Mailing Address - Country:US
Mailing Address - Phone:817-426-4401
Mailing Address - Fax:817-426-4410
Practice Address - Street 1:12770 SOUTH FWY
Practice Address - Street 2:SUITE 144
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-8447
Practice Address - Country:US
Practice Address - Phone:817-426-4401
Practice Address - Fax:817-426-4410
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1028421225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T4195OtherBLUE CROSS & BLUE SHIELD
TX8D5970Medicare ID - Type Unspecified