Provider Demographics
NPI:1073804084
Name:MARTIN, THOMAS EUGENE (IDC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:EUGENE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36329 SAINT RAPHAEL DR
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-8846
Mailing Address - Country:US
Mailing Address - Phone:951-764-4270
Mailing Address - Fax:
Practice Address - Street 1:36329 SAINT RAPHAEL DR
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8846
Practice Address - Country:US
Practice Address - Phone:951-764-4270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman