Provider Demographics
NPI:1780882068
Name:MARTIN, GREG (LMT)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 E POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7617
Mailing Address - Country:US
Mailing Address - Phone:503-669-9495
Mailing Address - Fax:503-669-8257
Practice Address - Street 1:837 E POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7617
Practice Address - Country:US
Practice Address - Phone:503-669-9495
Practice Address - Fax:503-669-8257
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10610174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist