Provider Demographics
NPI:1396724951
Name:MARTIN, JAMES D (DC, CCSP)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7018
Mailing Address - Country:US
Mailing Address - Phone:907-373-2022
Mailing Address - Fax:907-373-2029
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7018
Practice Address - Country:US
Practice Address - Phone:907-373-2022
Practice Address - Fax:907-373-2029
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA187111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCH0065Medicaid
AK920139651OtherEIN
AK920139651OtherEIN