Provider Demographics
NPI:1366205932
Name:MARTIN, MINERVA
Entity type:Individual
Prefix:
First Name:MINERVA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11024 WAHRMAN ST
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-3813
Mailing Address - Country:US
Mailing Address - Phone:313-784-5550
Mailing Address - Fax:734-941-6711
Practice Address - Street 1:11024 WAHRMAN ST
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-3813
Practice Address - Country:US
Practice Address - Phone:313-784-5550
Practice Address - Fax:313-784-5550
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM635603014055207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology