Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 2992 | TX |
NPI | 1770594517 |
---|---|
Provider Name | Michael C Martin |
First Address | Hurst, TX 76053-4290 |
Second Address | Hurst, TX 76053-4290 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8R9410 | BLUE CROSS BLUE SHIELD (01) | TX |
T14620 | (02) | TX |