Provider Demographics
NPI:1053346403
Name:MARTIN, CHUCK DONALD (MD)
Entity type:Individual
Prefix:
First Name:CHUCK
Middle Name:DONALD
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 1:1304 FAWCETT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1911
Mailing Address - Country:US
Mailing Address - Phone:253-680-3372
Mailing Address - Fax:253-383-3553
Practice Address - Street 1:1304 FAWCETT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1911
Practice Address - Country:US
Practice Address - Phone:253-680-3372
Practice Address - Fax:253-383-3553
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000419782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1001250Medicaid
WA8353732Medicaid
WAG8942782Medicare PIN
H52634Medicare UPIN
WAP00033082Medicare PIN
WAAB37346Medicare PIN
OR8801769Medicare PIN
WAG8942886Medicare PIN
WA8353732Medicaid
WAG8942791Medicare PIN
WAG8942779Medicare PIN