Provider Demographics
NPI:1477556009
Name:MARTENS, WILLI E (MD)
Entity type:Individual
Prefix:
First Name:WILLI
Middle Name:E
Last Name:MARTENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:1301 W 7TH ST
Practice Address - Street 2:SUITE 121
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-2651
Practice Address - Country:US
Practice Address - Phone:817-348-0425
Practice Address - Fax:817-348-0455
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25523207Q00000X
IL036-105818207Q00000X
WI29095-020207Q00000X
TXP7807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208967604Medicaid
421527584OtherTRI-CARE GROUP NUMBER
IAO278374Medicaid
IA0278374Medicaid
42152758404OtherJOHN DEERE
IAFQHCOther161816
IL421527584003Medicaid
33625OtherBLUE CROSS BLUE SHIELD
MO208967604Medicaid
IA0278374Medicaid