Provider Demographics
NPI:1285958769
Name:HAGAR, MARTIN BENJAMIN (PT, CSCS)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:BENJAMIN
Last Name:HAGAR
Suffix:
Gender:M
Credentials:PT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3336 E CHANDLER HEIGHTS RD
Mailing Address - Street 2:SUITE #126
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-4259
Mailing Address - Country:US
Mailing Address - Phone:480-840-6125
Mailing Address - Fax:480-840-6122
Practice Address - Street 1:3336 E CHANDLER HEIGHTS RD
Practice Address - Street 2:SUITE #126
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-4259
Practice Address - Country:US
Practice Address - Phone:480-840-6125
Practice Address - Fax:480-840-6122
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ036551Medicare UPIN