Provider Demographics
NPI:1659540441
Name:MARTIN, MARY (ADCS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ADCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8172 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-3441
Mailing Address - Country:US
Mailing Address - Phone:951-689-9366
Mailing Address - Fax:951-352-7374
Practice Address - Street 1:8310 BAXTER WAY
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-4302
Practice Address - Country:US
Practice Address - Phone:951-689-9366
Practice Address - Fax:951-352-7374
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA33352OtherDRUG MEDI-CAL