=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346662939
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DUANE MARTIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2014
-----------------------------------------------------
Last Update Date | 01/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1089 S JUSTINE CT
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85296-8653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-529-6159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1089 S JUSTINE CT
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85296-8653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-529-6159
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0905X
-----------------------------------------------------
Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | 30487
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------