Provider Demographics
NPI:1386602589
Name:MARTY, JOHN ALBERT JR (DPM)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALBERT
Last Name:MARTY
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 BLANEY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-3568
Mailing Address - Country:US
Mailing Address - Phone:724-543-3668
Mailing Address - Fax:724-543-2087
Practice Address - Street 1:186 BLANEY RD
Practice Address - Street 2:SUITE A
Practice Address - City:KITTANNING
Practice Address - State:PA
Practice Address - Zip Code:16201-3568
Practice Address - Country:US
Practice Address - Phone:724-543-3668
Practice Address - Fax:724-543-2087
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002620-L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009748630002Medicaid
PAT29396Medicare UPIN
PA130439Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER #
PA0256170004Medicare NSC