Provider Demographics
NPI:1538608906
Name:MICHAEL L MARTIN PH D PLLC
Entity type:Organization
Organization Name:MICHAEL L MARTIN PH D PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:918-619-7337
Mailing Address - Street 1:5555 E 71ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6542
Mailing Address - Country:US
Mailing Address - Phone:918-895-6294
Mailing Address - Fax:918-895-6295
Practice Address - Street 1:5555 E 71ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6542
Practice Address - Country:US
Practice Address - Phone:918-895-6294
Practice Address - Fax:918-895-6295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-18
Last Update Date:2017-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK764103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100840240AMedicaid