Provider Demographics
NPI:1952364341
Name:MARTIN, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARTIN
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 3136
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-2036
Mailing Address - Country:US
Mailing Address - Phone:860-896-1422
Mailing Address - Fax:860-896-1425
Practice Address - Street 1:1504 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2711
Practice Address - Country:US
Practice Address - Phone:860-644-1523
Practice Address - Fax:860-648-9468
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT018063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010018083CT02OtherANTHEM
CTP00087818OtherMEDICARE RAILROAD
CT1952364341Medicaid
CT018083OtherCTCARE
CT010018083CT02OtherANTHEM