Provider Demographics
NPI:1447338579
Name:WALL, MARTIN J (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:J
Last Name:WALL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1135 NE 116TH AVE
Mailing Address - Street 2:SUITE 620
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004
Mailing Address - Country:US
Mailing Address - Phone:425-454-8016
Mailing Address - Fax:425-453-2827
Practice Address - Street 1:1135 116TH AVE NE
Practice Address - Street 2:SUITE 620
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-454-8016
Practice Address - Fax:425-453-2827
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2022-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00034094208800000X
WA34094208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1033410Medicaid
WA1033410Medicaid
G16637Medicare UPIN