Basic Information
| Provider Information | |||||||||
| NPI: | 1154338549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | DEAN | ||||||||
| MiddleName: | ERWIN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 S PEORIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741203820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185881900 | ||||||||
| FaxNumber: | 9183821242 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 S PEORIA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741203820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185881900 | ||||||||
| FaxNumber: | 9183821242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 06/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 13789 | OK | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 100123800-A | 05 | OK | MEDICAID | 73-1042545 | 01 | OK | TRICARE GROUP # | OTHER | 73-1042545 | 01 | OK | GROUP MEDICARE | OTHER | 100732910 | 01 | OK | MEDICAID/SOONERCARE GROUP # | OTHER | 73-1042545 | 01 | OK | COMMUNITY CARE OF OKLAHOMA | OTHER | 73-1042545 | 01 | OK | BLUE CROSS BLUE SHEILD | OTHER |