Provider Demographics
NPI:1861911406
Name:MARTIN, MICHAEL DWAYNE (BA, MMIN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DWAYNE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:BA, MMIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 MERCHANT ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-4407
Mailing Address - Country:US
Mailing Address - Phone:614-657-8801
Mailing Address - Fax:
Practice Address - Street 1:16 W LONG ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2815
Practice Address - Country:US
Practice Address - Phone:614-225-0980
Practice Address - Fax:614-225-0986
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator