Healthcare Provider Details

I. General information

NPI: 1689615973
Provider Name (Legal Business Name): MARK LEE MARTIN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 E SARNIA ST
WINONA MN
55987-3803
US

IV. Provider business mailing address

350 E SARNIA ST
WINONA MN
55987-3803
US

V. Phone/Fax

Practice location:
  • Phone: 507-454-0646
  • Fax: 507-452-1446
Mailing address:
  • Phone: 507-454-0646
  • Fax: 507-452-1446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number31429
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31429
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number31429
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number31429
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: