Healthcare Provider Details

I. General information

NPI: 1225022106
Provider Name (Legal Business Name): RICHARD ALLAN MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SOUTH MOUNT AUBURN ROAD SUITE 420
CAPE GIRARDEAU MO
63703
US

IV. Provider business mailing address

150 SOUTH MOUNT AUBURN ROAD SUITE 420
CAPE GIRARDEAU MO
63703
US

V. Phone/Fax

Practice location:
  • Phone: 573-335-4448
  • Fax: 573-335-4466
Mailing address:
  • Phone: 573-335-4448
  • Fax: 573-335-4466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberR8494
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: