Healthcare Provider Details

I. General information

NPI: 1336105873
Provider Name (Legal Business Name): BRIAN MARTIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 12/04/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 MAPLE VALLEY DR
FARMINGTON MO
63640-1976
US

IV. Provider business mailing address

606 MAPLE VALLEY DR
FARMINGTON MO
63640-1976
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-7779
  • Fax: 888-849-3965
Mailing address:
  • Phone: 573-756-7779
  • Fax: 888-849-3965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005263
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2004019390
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: