Provider Demographics
NPI:1457397895
Name:MARTIN, THOMAS J (LAC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2144 SE 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3920
Mailing Address - Country:US
Mailing Address - Phone:503-784-7021
Mailing Address - Fax:
Practice Address - Street 1:1230 DIVISION ST
Practice Address - Street 2:OREGON CITY WELLNESS & FAMILY MEDICINE
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1521
Practice Address - Country:US
Practice Address - Phone:503-655-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00282171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist