Provider Demographics
NPI:1801328471
Name:MARTINO, ALYSE (MD)
Entity type:Individual
Prefix:
First Name:ALYSE
Middle Name:
Last Name:MARTINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 COOMBS FARM RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1150
Mailing Address - Country:US
Mailing Address - Phone:304-599-8000
Mailing Address - Fax:
Practice Address - Street 1:9000 COOMBS FARM RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-1149
Practice Address - Country:US
Practice Address - Phone:304-599-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-01
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC83800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC838008Medicaid