Provider Demographics
NPI:1992807762
Name:MARTIN, MADELEINE R
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:R
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 UNION ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-8600
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-992-2154
Practice Address - Street 1:1012 UNION ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3060
Practice Address - Country:US
Practice Address - Phone:207-945-5247
Practice Address - Fax:207-992-2154
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI172133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered