MEDICARE: MR. MARTIN L CROW IDC

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	171000000X	Military Health Care Provider
2	282N00000X	General Acute Care Hospital

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11111	OTHER	HI	USN-IDC

General Provider Information

NPI Number	:	1134341365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARTIN L CROW IDC

Provider Business Mailing Address
First Line	:	PO BOX 2788
Second Line	:
City	:	EWA BEACH
State	:	HI
Zip	:	96706-0788
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4725 BOUGAINVILLE DR
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96818-3179
Country	:	US
Telephone Number	:	619-944-8598
Fax Number	:

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	09/11/2025

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