Basic Information
Provider Information | |||||||||
NPI: | 1447221387 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MARTIN PODIATRY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MARTIN FOOT AND ANKLE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2300 PLEASANT VALLEY RD | ||||||||
Address2: |   | ||||||||
City: | YORK | ||||||||
State: | PA | ||||||||
PostalCode: | 174029627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7177573537 | ||||||||
FaxNumber: | 7177188674 | ||||||||
Practice Location | |||||||||
Address1: | 2300 PLEASANT VALLEY RD | ||||||||
Address2: |   | ||||||||
City: | YORK | ||||||||
State: | PA | ||||||||
PostalCode: | 174029627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7177573537 | ||||||||
FaxNumber: | 7177188674 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2006 | ||||||||
LastUpdateDate: | 01/24/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DUNKERLEY | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7177573537 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.P.M. | ||||||||
NPICertificationDate: | 01/24/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |   | 213ES0103X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 000886920007 | 05 | PA |   | MEDICAID |