Provider Demographics
NPI:1750609061
Name:MARTIN, BILLY ISAAC (C/OTA)
Entity type:Individual
Prefix:
First Name:BILLY
Middle Name:ISAAC
Last Name:MARTIN
Suffix:
Gender:M
Credentials:C/OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-1200
Mailing Address - Country:US
Mailing Address - Phone:580-795-3301
Mailing Address - Fax:580-795-7307
Practice Address - Street 1:306 DEER PARK RD
Practice Address - Street 2:
Practice Address - City:NEBO
Practice Address - State:NC
Practice Address - Zip Code:28761-8746
Practice Address - Country:US
Practice Address - Phone:828-652-8278
Practice Address - Fax:828-652-8278
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4740224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant