Provider Demographics
NPI:1083658579
Name:SCHLUSSELBERG, MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
Last Name:SCHLUSSELBERG
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 1:6869 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4219
Mailing Address - Country:US
Mailing Address - Phone:951-683-9999
Mailing Address - Fax:
Practice Address - Street 1:6869 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4219
Practice Address - Country:US
Practice Address - Phone:951-683-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41554174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C415540Medicaid
CA00C415540Medicare ID - Type Unspecified
CA00C415540Medicaid