Provider Demographics
NPI:1659878379
Name:COUSINEAU, MARTIN SHIELDS (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:SHIELDS
Last Name:COUSINEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9903 SANTA MONICA BLVD # 752
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-1671
Mailing Address - Country:US
Mailing Address - Phone:310-278-1172
Mailing Address - Fax:310-557-0049
Practice Address - Street 1:450 N ROXBURY DR STE 520
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4226
Practice Address - Country:US
Practice Address - Phone:310-278-1172
Practice Address - Fax:310-557-0049
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50372207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology