Basic Information
| Provider Information | |||||||||
| NPI: | 1598853939 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | STUART | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4655 N COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | SIERRA VISTA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856352497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204593012 | ||||||||
| FaxNumber: | 5204593207 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 E BELL RD STE 4 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850222692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025674800 | ||||||||
| FaxNumber: | 6025679939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 11/04/2017 | ||||||||
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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 | 207R00000X | 2010-00652 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 32483 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 28549 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 28549 | 01 | AZ | MEDICAL LICENSE | OTHER |