Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | A06075 | IA |
NPI | 1053416180 |
---|---|
Provider Name | Dr. Martin Stine |
First Address | Davenport, IA 52801-1417 |
Second Address | Davenport, IA 52801-1417 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2006 |
Last Update Date | 10/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
IB1811001 | (02) | IA |