Provider Demographics
NPI:1902913494
Name:MARTIN, STANLEY B (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:B
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 1:508 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2703
Mailing Address - Country:US
Mailing Address - Phone:636-946-3670
Mailing Address - Fax:636-946-5421
Practice Address - Street 1:508 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2703
Practice Address - Country:US
Practice Address - Phone:636-946-3670
Practice Address - Fax:636-946-5421
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102927207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506873009Medicaid
MO506873009Medicaid
140002666Medicare PIN
MOF53415Medicare UPIN