Healthcare Provider Details

I. General information

NPI: 1699724039
Provider Name (Legal Business Name): DOC MARTINS INC A C C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S YALE ST STE 150
FLAGSTAFF AZ
86001-7337
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 928-527-4325
  • Fax: 928-527-4327
Mailing address:
  • Phone: 702-954-7761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32052
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number32051
License Number StateAZ

VIII. Authorized Official

Name: EMILY CASTILLO
Title or Position: REGIONAL MANAGER
Credential:
Phone: 702-480-2550