Provider Demographics
NPI:1104806835
Name:MARTIN, ROBERT WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WAYNE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 E 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7229
Mailing Address - Country:US
Mailing Address - Phone:575-388-1819
Mailing Address - Fax:575-388-1972
Practice Address - Street 1:1290 E 32ND ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7229
Practice Address - Country:US
Practice Address - Phone:575-388-1819
Practice Address - Fax:575-388-1972
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0169207RC0000X
AZ20666207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM350764YKR1OtherMEDICARE PTAN
NM88659704Medicaid