Provider Demographics
NPI:1245213776
Name:MARTIN, MICHAEL E (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:MARTIN
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 1:2461 SUMMERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-7815
Mailing Address - Country:US
Mailing Address - Phone:707-525-0211
Mailing Address - Fax:707-525-0491
Practice Address - Street 1:2461 SUMMERFIELD RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7815
Practice Address - Country:US
Practice Address - Phone:707-525-0211
Practice Address - Fax:707-525-0491
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29076207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG29076OtherLICENSE
CAGR0061440Medicaid
CAZZZ95243ZMedicare ID - Type Unspecified
E25854Medicare UPIN