Provider Demographics
NPI:1629088026
Name:MARTIN, MICHAEL CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:MARTIN
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 1:12710 CARMEL COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2153
Mailing Address - Country:US
Mailing Address - Phone:858-499-2600
Mailing Address - Fax:858-481-9755
Practice Address - Street 1:12710 CARMEL COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2153
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:858-481-9755
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82624207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A826240Medicaid
CA00A826240Medicaid
CAWA82624AMedicare ID - Type Unspecified