Basic Information
| Provider Information | |||||||||
| NPI: | 1699724039 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOC MARTINS INC A C C | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLAGSTAFF FAMILY CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3190 N WINDSONG DR | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863142239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288005701 | ||||||||
| FaxNumber: | 9288005702 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 S YALE ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860017337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285274325 | ||||||||
| FaxNumber: | 9285274327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9285274325 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 32051 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 32051 | AZ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363LP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 207Q00000X | 32052 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.