MEDICARE: BRIAN MARTIN DPM

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	213ES0103X	Foot & Ankle Surgery Podiatrist	016005263	IL
2	213ES0103X	Foot & Ankle Surgery Podiatrist	2004019390	MO

General Provider Information

NPI Number	:	1336105873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN MARTIN DPM

Provider Business Mailing Address
First Line	:	606 MAPLE VALLEY DR
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1976
Country	:	US
Telephone Number	:	573-756-7779
Fax Number	:	888-849-3965

Provider Business Practice Location Address
First Line	:	606 MAPLE VALLEY DR
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1976
Country	:	US
Telephone Number	:	573-756-7779
Fax Number	:	888-849-3965

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

Provider Enumeration Date	:	04/24/2006
Last Update Date	:	12/04/2020

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Directions to “ BRIAN MARTIN DPM” Practice Location

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