Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | IL | |
N | 111NR0200X | Radiology | IL | |
N | 213ER0200X | Radiology | IL | |
N | 111NX0800X | Chiropractor Orthopedic Specialist | IL |
NPI | 1043222995 |
---|---|
Provider Name | Dr. Robert Donald Martin |
First Address | Johnston City, IL 62951-1604 |
Second Address | Johnston City, IL 62951-1604 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
073-82002 | BLUE CROSS/BLUE SHIELD (01) | IL |
T43086 | (02) | IL |