Healthcare Provider Details

I. General information

NPI: 1255621900
Provider Name (Legal Business Name): MICHAEL T MARTYAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 FAIRFAX AVE STE 610
NORFOLK VA
23507-1914
US

IV. Provider business mailing address

PO BOX 936
NORFOLK VA
23501-0936
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-5197
  • Fax: 757-446-5197
Mailing address:
  • Phone: 757-446-8960
  • Fax: 757-446-5197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number0101262206
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: