Provider Demographics
NPI:1497726525
Name:MARTIN, MARIO OSWALDO (IDC)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:OSWALDO
Last Name:MARTIN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 AGUA VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-5216
Mailing Address - Country:US
Mailing Address - Phone:619-723-6724
Mailing Address - Fax:
Practice Address - Street 1:2446 TRIDENT WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5494
Practice Address - Country:US
Practice Address - Phone:619-437-0777
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman