Provider Demographics
NPI:1295707859
Name:MARTIN, MARK A (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 PINESHORE CT
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47711-4473
Mailing Address - Country:US
Mailing Address - Phone:812-437-5554
Mailing Address - Fax:812-437-5577
Practice Address - Street 1:2112 PINESHORE CT
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47711-4473
Practice Address - Country:US
Practice Address - Phone:812-437-5554
Practice Address - Fax:812-437-5577
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002206A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200355030AMedicaid
IN000000324829OtherBCBS WOUND CARE
IN2296702OtherWELBORN HMO - WOUND CARE
IN200355030AMedicaid
IN213780Medicare PIN
H33744Medicare UPIN
IN253060AMedicare PIN