Provider Demographics
NPI:1457687204
Name:ATALLA, MARTA IMA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTA
Middle Name:IMA
Last Name:ATALLA
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 1:557 N MACLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-2424
Mailing Address - Country:US
Mailing Address - Phone:818-639-0209
Mailing Address - Fax:818-639-0210
Practice Address - Street 1:557 N MACLAY AVE
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-2424
Practice Address - Country:US
Practice Address - Phone:818-639-0210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ART2009-123208000000X
CAA121879208000000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR061833974Medicaid
CA1457687204Medicaid