Healthcare Provider Details

I. General information

NPI: 1760685838
Provider Name (Legal Business Name): MICHAEL DAVID MARTIN MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 KENNY ROAD SUITE 3100
COLUMBUS OH
43221
US

IV. Provider business mailing address

520 OAK TREE AVE
PICKERINGTON OH
43147-1077
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-2385
  • Fax: 614-293-3066
Mailing address:
  • Phone: 614-920-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number10533
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: