Healthcare Provider Details

I. General information

NPI: 1275722589
Provider Name (Legal Business Name): SCOT A. MARTIN, M.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 S ROADRUNNER PKWY SUITE 129
LAS CRUCES NM
88011-2006
US

IV. Provider business mailing address

141 S ROADRUNNER PKWY SUITE 129
LAS CRUCES NM
88011-2006
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-7111
  • Fax: 575-521-0563
Mailing address:
  • Phone: 575-521-7111
  • Fax: 575-521-0563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number2002-0069
License Number StateNM

VIII. Authorized Official

Name: DR. SCOT A MARTIN
Title or Position: OWNER
Credential: M.D.
Phone: 575-521-7111