Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | G29076 | CA |
NPI | 1245213776 |
---|---|
Provider Name | Mr. Michael E Martin |
First Address | Santa Rosa, CA 95405-7815 |
Second Address | Santa Rosa, CA 95405-7815 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/11/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E25854 | (02) | |
G29076 | LICENSE (01) | CA |
GR0061440 | (05) | CA |