Basic Information
| Provider Information | |||||||||
| NPI: | 1851475610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | LEROY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25138 W. BLUE SKY DRIVE | ||||||||
| Address2: | |||||||||
| City: | WHITTMANN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403123140 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3800 W RAY RD STE 5 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852265940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807185400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | POD-000813 | AZ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 36003308M | OH | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2338992 | 05 | OH | MEDICAID |