Provider Demographics
NPI:1497786446
Name:MD MART, INC
Entity Type:Organization
Organization Name:MD MART, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:COATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-960-5409
Mailing Address - Street 1:1630 OAKLAND RD
Mailing Address - Street 2:STE A108
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-2449
Mailing Address - Country:US
Mailing Address - Phone:408-453-6468
Mailing Address - Fax:408-453-6461
Practice Address - Street 1:1630 OAKLAND RD
Practice Address - Street 2:STE A108
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-2449
Practice Address - Country:US
Practice Address - Phone:408-960-5409
Practice Address - Fax:408-453-6461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03435FMedicaid
CADME03435FMedicaid