Provider Demographics
NPI:1063504058
Name:O'TOOLE, MARTIN A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:A
Last Name:O'TOOLE
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:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91012-0158
Mailing Address - Country:US
Mailing Address - Phone:626-449-8910
Mailing Address - Fax:
Practice Address - Street 1:542 S FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2606
Practice Address - Country:US
Practice Address - Phone:626-449-8910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67312208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G673120Medicaid
CAG30064Medicare UPIN
CA00G673120Medicaid