Provider Demographics
NPI:1790857068
Name:BERTRAM, MARTIN F (MD)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:F
Last Name:BERTRAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-0337
Mailing Address - Country:US
Mailing Address - Phone:801-773-4840
Mailing Address - Fax:801-525-8151
Practice Address - Street 1:1750 E 3100 N
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040-2406
Practice Address - Country:US
Practice Address - Phone:801-773-4840
Practice Address - Fax:801-525-8151
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8858473-1205208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
31164836000OtherWORKERS COMP
OH0110963Medicaid
000000038962OtherBCBS
OH0110963Medicaid
0775999Medicare PIN