Provider Demographics
NPI:1669427613
Name:MARTIN, BENJAMIN J (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:J
Last Name:MARTIN
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 1:615 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NE
Mailing Address - Zip Code:68787-1152
Mailing Address - Country:US
Mailing Address - Phone:402-375-2500
Mailing Address - Fax:402-375-2463
Practice Address - Street 1:615 E 14TH ST
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NE
Practice Address - Zip Code:68787-1152
Practice Address - Country:US
Practice Address - Phone:402-375-2500
Practice Address - Fax:402-375-2463
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE16684207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE0565689Medicaid
NE274756Medicare PIN
E66951Medicare UPIN