Provider Demographics
NPI:1770578361
Name:MARTIN, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:600 NW MURRAY RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-1204
Mailing Address - Country:US
Mailing Address - Phone:816-524-2626
Mailing Address - Fax:816-524-0173
Practice Address - Street 1:600 NW MURRAY RD
Practice Address - Street 2:SUITE 210
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-1204
Practice Address - Country:US
Practice Address - Phone:816-524-2626
Practice Address - Fax:816-524-0173
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2009-12-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOMD 35980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100453490AMedicaid
MO201211018Medicaid
MOC51290Medicare UPIN
KS100453490AMedicaid