Basic Information
| Provider Information | |||||||||
| NPI: | 1669678595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | GARRY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 E 104TH ST | ||||||||
| Address2: | MAILSTOP 400N | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641314517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165028756 | ||||||||
| FaxNumber: | 8169329670 | ||||||||
| Practice Location | |||||||||
| Address1: | 4320 WORNALL RD | ||||||||
| Address2: | STE 530 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641115941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9139320288 | ||||||||
| FaxNumber: | 8169329868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 08/01/2016 | ||||||||
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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 | 208200000X | UNKNOWN | KS | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.