Provider Demographics
NPI:1033168810
Name:KABONGO, MARTIN L (MD, APC)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:L
Last Name:KABONGO
Suffix:
Gender:M
Credentials:MD, APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:858-249-6749
Mailing Address - Fax:
Practice Address - Street 1:UCSD MEDICAL CENTER
Practice Address - Street 2:200 WEST ARBOR DRIVE MC8201
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-8201
Practice Address - Country:US
Practice Address - Phone:858-657-7750
Practice Address - Fax:619-543-3183
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A550120Medicaid
CAWA55012IMedicare ID - Type Unspecified
CA00A550120Medicaid