Healthcare Provider Details

I. General information

NPI: 1114176567
Provider Name (Legal Business Name): MARTIN WHITMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N 35TH AVE STE 465
HOLLYWOOD FL
33021-5467
US

IV. Provider business mailing address

1150 N 35TH AVE STE 465
HOLLYWOOD FL
33021-5467
US

V. Phone/Fax

Practice location:
  • Phone: 954-986-9008
  • Fax: 954-986-6646
Mailing address:
  • Phone: 954-986-9008
  • Fax: 954-986-6646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3119
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: