Healthcare Provider Details

I. General information

NPI: 1710934302
Provider Name (Legal Business Name): MARTIN MAIMON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 14TH AVE SE
PUYALLUP WA
98372-3770
US

IV. Provider business mailing address

407 14TH AVE SE
PUYALLUP WA
98372-3770
US

V. Phone/Fax

Practice location:
  • Phone: 253-697-4110
  • Fax:
Mailing address:
  • Phone: 253-697-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00038662
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: