Provider Demographics
NPI:1710484530
Name:MARTIN, KEVIN MARK (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MARK
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25470 MEDICAL CENTER DR STE 102
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-4901
Mailing Address - Country:US
Mailing Address - Phone:951-698-6090
Mailing Address - Fax:888-696-2612
Practice Address - Street 1:25470 MEDICAL CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-4901
Practice Address - Country:US
Practice Address - Phone:951-698-6090
Practice Address - Fax:888-696-2612
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A18055207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine