Provider Demographics
NPI:1316236797
Name:MARTIN, TREVER J (DPM)
Entity type:Individual
Prefix:DR
First Name:TREVER
Middle Name:J
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DPM
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Mailing Address - Street 1:1202 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-2715
Mailing Address - Country:US
Mailing Address - Phone:208-365-2338
Mailing Address - Fax:208-365-0677
Practice Address - Street 1:1024 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617
Practice Address - Country:US
Practice Address - Phone:208-365-2338
Practice Address - Fax:208-365-0677
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-227213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20005139OtherMEDICARE PTAN
ID820382500OtherTAX ID
ID1316236797OtherNPI