Provider Demographics
NPI:1184899254
Name:MARTIN, THOMAS ELLSWORTH JR (DC)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ELLSWORTH
Last Name:MARTIN
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 N PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2101
Mailing Address - Country:US
Mailing Address - Phone:610-565-9426
Mailing Address - Fax:610-565-8982
Practice Address - Street 1:1020 N PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-2101
Practice Address - Country:US
Practice Address - Phone:610-565-9426
Practice Address - Fax:610-565-8982
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA5118111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA703722Medicare PIN