Provider Demographics
NPI:1033293261
Name:MARTIN, WAYNE HAMILTON (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:HAMILTON
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 GRAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4171
Mailing Address - Country:US
Mailing Address - Phone:909-860-6768
Mailing Address - Fax:909-860-4224
Practice Address - Street 1:1111 GRAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4171
Practice Address - Country:US
Practice Address - Phone:909-860-6768
Practice Address - Fax:909-860-4224
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56034207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G560342Medicaid
CAAT953ZMedicare PIN
CA00G560342Medicaid
CAG56034BMedicare PIN
CAA93418Medicare UPIN