Provider Demographics
NPI:1801874417
Name:MARTIN, REBECCA M (DO)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:M
Last Name:MARTIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10906 W SYCAMORE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-9334
Mailing Address - Country:US
Mailing Address - Phone:260-625-5540
Mailing Address - Fax:
Practice Address - Street 1:10906 W SYCAMORE HILLS DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9334
Practice Address - Country:US
Practice Address - Phone:260-625-5540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001840A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D14971Medicare UPIN