Provider Demographics
NPI:1639130248
Name:SCHMIDT, MARTY LEE (MD)
Entity type:Individual
Prefix:MR
First Name:MARTY
Middle Name:LEE
Last Name:SCHMIDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 N FOWLER ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-2312
Mailing Address - Country:US
Mailing Address - Phone:575-392-2040
Mailing Address - Fax:575-392-6752
Practice Address - Street 1:2410 N FOWLER ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-2312
Practice Address - Country:US
Practice Address - Phone:575-392-2040
Practice Address - Fax:575-392-6752
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0422840208000000X
NMMD20070006208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100126120BMedicaid
MO24709030OtherBCBS
NM02926369Medicaid
MO2033619828Medicaid
632400OtherFIRSTGUARD