Healthcare Provider Details

I. General information

NPI: 1174582126
Provider Name (Legal Business Name): ANITA LOUISE MARTIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 04/14/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 ELBOWOODS LOOP
NEW TOWN ND
58763
US

IV. Provider business mailing address

1251 ELBOWOODS LOOP
NEW TOWN ND
58763
US

V. Phone/Fax

Practice location:
  • Phone: 701-627-4750
  • Fax: 701-627-3803
Mailing address:
  • Phone: 701-627-4750
  • Fax: 701-627-3803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number30406
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7422261
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerAETNA
# 2
Identifier54142
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBLUE CROSS BLUE SHIELD
# 3
Identifier8954142
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: