Healthcare Provider Details

I. General information

NPI: 1790726768
Provider Name (Legal Business Name): MICHAEL J MARTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 W UNION AVE
TACOMA WA
98405-2099
US

IV. Provider business mailing address

805 MADISON ST SUITE 901
SEATTLE WA
98104-1172
US

V. Phone/Fax

Practice location:
  • Phone: 253-572-2663
  • Fax: 253-752-1160
Mailing address:
  • Phone: 206-264-8100
  • Fax: 206-264-8689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberMD00031212
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: