Provider Demographics
NPI:1699776930
Name:MACNEILL, MARTIN (DO)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:MACNEILL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 N 900 E
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-9183
Mailing Address - Country:US
Mailing Address - Phone:801-763-4201
Mailing Address - Fax:801-763-4073
Practice Address - Street 1:895 N 900 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-9183
Practice Address - Country:US
Practice Address - Phone:801-763-4201
Practice Address - Fax:801-763-4073
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT177717-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE33813Medicare UPIN
UT007074014Medicare ID - Type Unspecified