Provider Demographics
NPI:1336107531
Name:MARTIN, CHARMAINE ALICIA (MD)
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:ALICIA
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 1:5130 GATEWAY BLVD E # 51015
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1608
Mailing Address - Country:US
Mailing Address - Phone:915-215-4480
Mailing Address - Fax:915-215-5386
Practice Address - Street 1:9849 KENWORTHY ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-4402
Practice Address - Country:US
Practice Address - Phone:915-545-9795
Practice Address - Fax:915-545-9799
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3312207Q00000X
TX41163 TEMPORARY207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177228702Medicaid
TX8R5088OtherBCBS OF TEXAS
TX8G1885Medicare ID - Type Unspecified
TX8R5088OtherBCBS OF TEXAS