Provider Demographics
NPI:1073703682
Name:MARTIN, JUDITH ANN (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1124 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-4331
Mailing Address - Country:US
Mailing Address - Phone:510-533-0800
Mailing Address - Fax:510-898-2183
Practice Address - Street 1:1124 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-4331
Practice Address - Country:US
Practice Address - Phone:510-533-0800
Practice Address - Fax:510-898-2183
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38355207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF13889Medicare UPIN