Provider Demographics
NPI:1487692224
Name:MARTIN, TIMOTHY A (DC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 CONCHESTER HWY
Mailing Address - Street 2:SUITE 15C
Mailing Address - City:BOOTHWYN
Mailing Address - State:PA
Mailing Address - Zip Code:19061-2124
Mailing Address - Country:US
Mailing Address - Phone:610-361-0070
Mailing Address - Fax:610-361-0071
Practice Address - Street 1:1440 CONCHESTER HWY
Practice Address - Street 2:SUITE 15C
Practice Address - City:BOOTHWYN
Practice Address - State:PA
Practice Address - Zip Code:19061-2124
Practice Address - Country:US
Practice Address - Phone:610-361-0070
Practice Address - Fax:610-361-0071
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008836111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA058465Medicare ID - Type Unspecified