Provider Demographics
NPI:1689361685
Name:MARTIN, CLARENCE SR
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:
Last Name:MARTIN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 KEARNY MESA RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-1303
Mailing Address - Country:US
Mailing Address - Phone:619-717-2363
Mailing Address - Fax:
Practice Address - Street 1:5400 KEARNY MESA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1303
Practice Address - Country:US
Practice Address - Phone:619-717-2363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist