Provider Demographics
NPI:1780946236
Name:MARTHAKIS, NANCY (DO)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:MARTHAKIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8540 105TH AVE
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49346-9764
Mailing Address - Country:US
Mailing Address - Phone:219-763-8112
Mailing Address - Fax:219-764-6348
Practice Address - Street 1:3355 EAGLE PARK DR NE STE 103
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7004
Practice Address - Country:US
Practice Address - Phone:616-942-7400
Practice Address - Fax:616-942-7405
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004027A207R00000X
MI5101020834207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1780946236Medicaid
MI1780946236Medicaid
MIE46007016Medicare Oscar/Certification