Provider Demographics
NPI:1386678746
Name:CHENEVERT, MARTIN LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:LOUIS
Last Name:CHENEVERT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1990 N CALIFORNIA BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-3742
Mailing Address - Country:US
Mailing Address - Phone:925-482-2811
Mailing Address - Fax:925-482-2834
Practice Address - Street 1:1250 16TH ST
Practice Address - Street 2:SANTA MONICA-UCLA MEDICAL CENTER, EMERGENCY DEPT.
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1249
Practice Address - Country:US
Practice Address - Phone:424-259-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG067565207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE0773ZMedicare UPIN
CAE85699Medicare UPIN