Provider Demographics
NPI:1649357211
Name:MARTIN, DOUGLASS EUGENE (EDD)
Entity type:Individual
Prefix:DR
First Name:DOUGLASS
Middle Name:EUGENE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4013 NE 57TH PL
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64119-2268
Mailing Address - Country:US
Mailing Address - Phone:816-536-1828
Mailing Address - Fax:816-413-5305
Practice Address - Street 1:4013 NE 57TH PL
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64119-2268
Practice Address - Country:US
Practice Address - Phone:816-536-1828
Practice Address - Fax:816-413-5305
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY000307103T00000X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO16469011OtherBC/BS PROVIDER #