Provider Demographics
NPI:1972788305
Name:MARTIN, DAVID A (OTR/L)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:MARTIN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 W ERNESTINE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5800
Mailing Address - Country:US
Mailing Address - Phone:618-993-6237
Mailing Address - Fax:618-997-3529
Practice Address - Street 1:3905 W ERNESTINE DR
Practice Address - Street 2:SUITE B
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5800
Practice Address - Country:US
Practice Address - Phone:618-993-6237
Practice Address - Fax:618-997-3529
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056006919225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213486OtherGROUP
IL056-006919OtherSTATE LICENSE NO.
ILT01063Medicare PIN