Basic Information
Provider Information | |||||||||
NPI: | 1881679397 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARTIN | ||||||||
FirstName: | TROY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 50150 | ||||||||
Address2: |   | ||||||||
City: | BELLEVUE | ||||||||
State: | WA | ||||||||
PostalCode: | 980150150 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252285228 | ||||||||
FaxNumber: | 4252285733 | ||||||||
Practice Location | |||||||||
Address1: | 10631 EIGHTH AVENUE NORTHEAST | ||||||||
Address2: | KINDRED HOSPITAL SEATTLE | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 98125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2063617431 | ||||||||
FaxNumber: | 2063617452 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/08/2005 | ||||||||
LastUpdateDate: | 06/29/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD60002235 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RI0200X | MD11639 | RI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | MD60002235 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
ID | Type | State | Issuer | Description | 1881679397 | 05 | WA |   | MEDICAID | 7057246 | 05 | RI |   | MEDICAID |