Basic Information
| Provider Information | |||||||||
| NPI: | 1477556009 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTENS | ||||||||
| FirstName: | WILLI | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1239 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480991239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488246600 | ||||||||
| FaxNumber: | 8556186655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 W 7TH ST | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761022651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173480425 | ||||||||
| FaxNumber: | 8173480455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 07/14/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25523 | IA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036-105818 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 29095-020 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | P7807 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208967604 | 05 | MO | MEDICAID | 421527584 | 01 | TRI-CARE GROUP NUMBER | OTHER | O278374 | 05 | IA | MEDICAID | 0278374 | 05 | IA | MEDICAID | 42152758404 | 01 | JOHN DEERE | OTHER | FQHC | 01 | IA | 161816 | OTHER | 421527584003 | 05 | IL | MEDICAID | 33625 | 01 | BLUE CROSS BLUE SHIELD | OTHER |