MEDICARE: PROF. WAYNE ROBERT MARTIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	42227	AZ
2	207Q00000X	Family Medicine Physician	7466	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8V4761	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1104867621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. WAYNE ROBERT MARTIN MD

Provider Business Mailing Address
First Line	:	1606 N PANORAMA WAY
Second Line	:
City	:	COCHISE
State	:	AZ
Zip	:	85606-8685
Country	:	US
Telephone Number	:	701-880-0826
Fax Number	:

Provider Business Practice Location Address
First Line	:	1606 N PANORAMA WAY
Second Line	:
City	:	COCHISE
State	:	AZ
Zip	:	85606-8685
Country	:	US
Telephone Number	:	701-880-0826
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	10/31/2023

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