=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538608906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL L MARTIN PH D PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2017
-----------------------------------------------------
Last Update Date | 02/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5555 E 71ST ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-6542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-895-6294
-----------------------------------------------------
Fax | 918-895-6295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5555 E 71ST ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-6542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-895-6294
-----------------------------------------------------
Fax | 918-895-6295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL L MARTIN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 918-619-7337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 764
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------