Provider Demographics
NPI:1578512950
Name:MARTIN, BRADY C (PT)
Entity Type:Individual
Prefix:MR
First Name:BRADY
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26400 LA ALAMEDA STE 202
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8577
Mailing Address - Country:US
Mailing Address - Phone:949-347-1021
Mailing Address - Fax:949-347-0981
Practice Address - Street 1:26400 LA ALAMEDA STE 202
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-8577
Practice Address - Country:US
Practice Address - Phone:949-347-1021
Practice Address - Fax:949-347-0981
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA233772251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT22377COtherPPIN
CAS81684Medicare UPIN
CAW15749Medicare ID - Type Unspecified