Provider Demographics
NPI:1679344030
Name:MARTIN, KYLE RICHARD
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:RICHARD
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COLLEGE HL
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MO
Mailing Address - Zip Code:63435-1299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 COLLEGE HL
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MO
Practice Address - Zip Code:63435-1257
Practice Address - Country:US
Practice Address - Phone:573-288-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOC054365002207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine