Provider Demographics
NPI:1548252992
Name:MARTIN, MARK ALAN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 NW LOVEJOY ST
Mailing Address - Street 2:SUITE 315
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5101
Mailing Address - Country:US
Mailing Address - Phone:503-266-6321
Mailing Address - Fax:503-227-3422
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:SUITE 315
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5101
Practice Address - Country:US
Practice Address - Phone:503-266-6321
Practice Address - Fax:503-227-3422
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD20553208G00000X
WAMD00035549208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150363Medicaid
WA8218232Medicaid
OR116055Medicare PIN
OR115796Medicare PIN
OR150363Medicaid
OR152561Medicare PIN
WA8218232Medicaid