Provider Demographics
NPI:1811926561
Name:MARTINO, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MARTINO
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 1:1200 CARSON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2700
Mailing Address - Country:US
Mailing Address - Phone:719-383-5970
Mailing Address - Fax:719-383-5974
Practice Address - Street 1:1200 CARSON AVE STE 102
Practice Address - Street 2:
Practice Address - City:LA JUNTA
Practice Address - State:CO
Practice Address - Zip Code:81050-2700
Practice Address - Country:US
Practice Address - Phone:719-383-5970
Practice Address - Fax:719-383-5974
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR36536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO80164496OtherRAILROAD MEDICARE
COMAM6084OtherBLUE CROSS
CO01365360Medicaid
COMAM6084OtherBLUE CROSS
G71461Medicare UPIN