Healthcare Provider Details

I. General information

NPI: 1598144867
Provider Name (Legal Business Name): MARTIN OKUN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2015
Last Update Date: 02/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 SHERMAN AVE E 3RD FLOOR
FORT ATKINSON WI
53538-1960
US

IV. Provider business mailing address

611 SHERMAN AVE E 3RD FLOOR
FORT ATKINSON WI
53538-1960
US

V. Phone/Fax

Practice location:
  • Phone: 920-568-1000
  • Fax: 920-568-5477
Mailing address:
  • Phone: 920-568-1000
  • Fax: 920-568-5477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number43279-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: