Basic Information
| Provider Information | |||||||||
| NPI: | 1316224058 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY WADE MARTIN MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 608 NW 9TH ST | ||||||||
| Address2: | SUITE 5010 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052727026 | ||||||||
| FaxNumber: | 4052727027 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 NW 9TH ST | ||||||||
| Address2: | SUITE 5010 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052727026 | ||||||||
| FaxNumber: | 4052727027 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2011 | ||||||||
| LastUpdateDate: | 10/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | WADE | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4059360504 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 23664 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 200016330A | 05 | OK | MEDICAID |