Healthcare Provider Details

I. General information

NPI: 1619175031
Provider Name (Legal Business Name): WILLIAM W. MARTIN, DPM, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 1/2 N MAIN ST
LOGAN UT
84321-3915
US

IV. Provider business mailing address

272 1/2 N MAIN ST
LOGAN UT
84321-3915
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-3953
  • Fax: 877-447-7294
Mailing address:
  • Phone: 435-753-3953
  • Fax: 877-447-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5101098-0501
License Number StateUT

VII. Legacy identifiers

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

VIII. Authorized Official

Name: WILLIAM MARTIN
Title or Position: OWNER
Credential: DPM
Phone: 435-753-3953