Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223G0001X | General Practice | 19025300 | IL |
N | 213EG0000X | General Practice | 19025300 | IL |
Y | 1223P0106X | Oral and Maxillofacial Pathology | 19025300 | IL |
NPI | 1538336615 |
---|---|
Provider Name | Dr. Brent D Martin |
First Address | Jbsa Ft Sam Houston, TX 78234-4504 |
Second Address | Jbsa Ft Sam Houston, TX 78234-4504 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2008 |
Last Update Date | 20/02/2019 |