Provider Demographics
NPI:1558633842
Name:DANIEL J MARTIN JR MD LLC
Entity type:Organization
Organization Name:DANIEL J MARTIN JR MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:314-567-5850
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:5015B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-567-5850
Mailing Address - Fax:314-567-9169
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:5015B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-567-5850
Practice Address - Fax:314-567-9169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR1P08174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE95563Medicare UPIN