Provider Demographics
NPI:1740543024
Name:MARTIN, KENNETH ALAN (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MATTHEW ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750
Mailing Address - Country:US
Mailing Address - Phone:740-376-1939
Mailing Address - Fax:
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-374-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3098207P00000X
OH34011850207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0129985Medicaid
OH0129985Medicaid