Basic Information
| Provider Information | |||||||||
| NPI: | 1548252992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 NW LOVEJOY ST | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972105101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032666321 | ||||||||
| FaxNumber: | 5032273422 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 NW LOVEJOY ST | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972105101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032666321 | ||||||||
| FaxNumber: | 5032273422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 09/01/2015 | ||||||||
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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 | 208G00000X | MD20553 | OR | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | MD00035549 | WA | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 150363 | 05 | OR | MEDICAID | 8218232 | 05 | WA | MEDICAID |