Healthcare Provider Details

I. General information

NPI: 1336150267
Provider Name (Legal Business Name): BETH ANN MARTIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 W PARK PL
COEUR D ALENE ID
83814-2785
US

IV. Provider business mailing address

PO BOX 1387
HAYDEN ID
83835-1387
US

V. Phone/Fax

Practice location:
  • Phone: 208-215-2005
  • Fax:
Mailing address:
  • Phone: 208-415-0299
  • Fax: 208-625-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM7951
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: