Provider Demographics
NPI:1699732578
Name:MARTIN, TEACKLE W JR (MD)
Entity type:Individual
Prefix:
First Name:TEACKLE
Middle Name:W
Last Name:MARTIN
Suffix:JR
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 1:1400 E. KINCAID STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:1900 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284
Practice Address - Country:US
Practice Address - Phone:360-856-4222
Practice Address - Fax:360-854-2792
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014430207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1543602Medicaid
WA263561OtherLABOR & INDUSTRIES
WAA09007Medicare UPIN
WAAB21979Medicare ID - Type Unspecified
WA8892578Medicare PIN