Provider Demographics
NPI:1912169095
Name:MARTIN, MATTHEW D (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:245 CHERRY ST SE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4607
Mailing Address - Country:US
Mailing Address - Phone:616-459-4131
Mailing Address - Fax:616-459-6030
Practice Address - Street 1:245 CHERRY ST SE
Practice Address - Street 2:SUITE 302
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4607
Practice Address - Country:US
Practice Address - Phone:616-459-4131
Practice Address - Fax:616-459-6030
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092559208600000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program