Provider Demographics
NPI:1740281138
Name:MARTINO, GREGORY M (PHD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:M
Last Name:MARTINO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 MC CRACKEN RUN ROAD
Mailing Address - Street 2:
Mailing Address - City:DUBOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-3634
Mailing Address - Country:US
Mailing Address - Phone:814-371-2577
Mailing Address - Fax:814-371-2577
Practice Address - Street 1:214 MC CRACKEN RUN ROAD
Practice Address - Street 2:
Practice Address - City:DUBOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-3634
Practice Address - Country:US
Practice Address - Phone:814-371-2577
Practice Address - Fax:814-371-2577
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008503L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00067507OtherRAILROAD
340518OtherHIGHMARK
021494OtherMEDICARE IDENTIFICATION NUMBER
PA0019479780003Medicaid
021494OtherMEDICARE IDENTIFICATION NUMBER