Healthcare Provider Details

I. General information

NPI: 1902862675
Provider Name (Legal Business Name): WADE HAMPTON MARTIN III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD 111A/JC
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

6626 WATERMAN AVE
UNIVERSITY CITY MO
63130-4659
US

V. Phone/Fax

Practice location:
  • Phone: 314-289-6329
  • Fax: 314-289-7029
Mailing address:
  • Phone: 314-863-9207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberR9135
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: