Provider Demographics
NPI:1275580680
Name:MARTIN, PHILLIP ALLAN (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ALLAN
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 1:19963 WALKER BASIN RD
Mailing Address - Street 2:
Mailing Address - City:CALIENTE
Mailing Address - State:CA
Mailing Address - Zip Code:93518-4124
Mailing Address - Country:US
Mailing Address - Phone:661-867-1100
Mailing Address - Fax:
Practice Address - Street 1:6425 LYNCH CANYON DR
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-9726
Practice Address - Country:US
Practice Address - Phone:760-379-8630
Practice Address - Fax:760-379-7658
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61763207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G617630Medicaid
CA00G617630Medicaid