Provider Demographics
NPI:1679590202
Name:MARTIN, DALLAS B (DO)
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:B
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 SKYTOP CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2222
Mailing Address - Country:US
Mailing Address - Phone:304-610-3704
Mailing Address - Fax:
Practice Address - Street 1:1106 SKYTOP CIR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-2222
Practice Address - Country:US
Practice Address - Phone:304-610-3704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1048207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0042041000Medicaid
WV2033473Medicare PIN
WV2033475Medicare PIN
WV2033474Medicare PIN
WV2033471Medicare PIN
WV2033472Medicare PIN
WV2033476Medicare PIN