Healthcare Provider Details

I. General information

NPI: 1568430304
Provider Name (Legal Business Name): MARTIN HURTADO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 TENNYSON AVE STE 201
EUGENE OR
97408-4693
US

IV. Provider business mailing address

2911 TENNYSON AVE STE 201
EUGENE OR
97408-4693
US

V. Phone/Fax

Practice location:
  • Phone: 541-844-1495
  • Fax: 541-844-1495
Mailing address:
  • Phone: 541-844-1495
  • Fax: 541-844-1492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD24983
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier275318
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: