Healthcare Provider Details

I. General information

NPI: 1609187566
Provider Name (Legal Business Name): REG MARTIN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 09/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6819 PLUM CREEK DR
AMARILLO TX
79124-1602
US

IV. Provider business mailing address

PO BOX 2265
AMARILLO TX
79105-2265
US

V. Phone/Fax

Practice location:
  • Phone: 806-212-2000
  • Fax:
Mailing address:
  • Phone: 806-355-9595
  • Fax: 806-353-1589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberL4053
License Number StateTX

VIII. Authorized Official

Name: REG MARTIN
Title or Position: OWNER
Credential: MD
Phone: 806-355-9595