Provider Demographics
NPI:1134294564
Name:MARTIN, MYRA C (MD)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:C
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:PO BOX 7001
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-7001
Mailing Address - Country:US
Mailing Address - Phone:818-888-7815
Mailing Address - Fax:818-715-1722
Practice Address - Street 1:23845 MCBEAN PKWY
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-2001
Practice Address - Country:US
Practice Address - Phone:661-253-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA904109207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA904109AOtherMEDICARE PPIN
CAAT767ZMedicare PIN
CAWA904109AOtherMEDICARE PPIN