Provider Demographics
NPI: | 1700896131 |
---|---|
Name: | MARTIN, WILLIAM (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | WILLIAM |
Middle Name: | |
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: | 325 PARK AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | HUNTINGTON |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 11743-2779 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 631-351-3758 |
Mailing Address - Fax: | 631-351-3712 |
Practice Address - Street 1: | 325 PARK AVE |
Practice Address - Street 2: | |
Practice Address - City: | HUNTINGTON |
Practice Address - State: | NY |
Practice Address - Zip Code: | 11743-2779 |
Practice Address - Country: | US |
Practice Address - Phone: | 631-351-3758 |
Practice Address - Fax: | 631-351-3712 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-08 |
Last Update Date: | 2008-07-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 168911-1 | 2086S0129X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NY | 01340252 | Medicaid | |
NY | 20813 | Other | GHI |
NY | CS274 | Other | OXFORD |
NY | 2C4864 | Other | HEALTHNET |
NY | 53K241 | Other | BLUE CROSS/ BLUE SHIELD |
NY | 2C4864 | Other | HEALTHNET |
NY | 53K241 | Medicare ID - Type Unspecified |