Basic Information
| Provider Information | |||||||||
| NPI: | 1942415369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTUCCI | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 E HARMONY RD UNIT 290 | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702212370 | ||||||||
| FaxNumber: | 9702219654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2007 | ||||||||
| LastUpdateDate: | 07/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 9767A | WY | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207K00000X | DR.0048242 | CO | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 135469800 | 05 | WY | MEDICAID | 391620ZMHC | 01 | CO | MEDICARE PTAN | OTHER | 10027065300 | 05 | NE | MEDICAID | 30928371 | 05 | CO | MEDICAID | W27146 | 01 | WY | MEDICARE PTAN | OTHER |