Provider Demographics
NPI:1760002968
Name:MARTIN, SAMUEL JEFFREY
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JEFFREY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 WAYZATA BLVD APT 406
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2149
Mailing Address - Country:US
Mailing Address - Phone:952-807-5384
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST STE 1750
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3799
Practice Address - Country:US
Practice Address - Phone:952-807-5384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN76729208100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation