Provider Demographics
NPI:1720029887
Name:MARTIN, GLORIA L (MD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:L
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SHADOW LANE
Mailing Address - Street 2:SUITE #165
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106
Mailing Address - Country:US
Mailing Address - Phone:702-522-9640
Mailing Address - Fax:702-522-9641
Practice Address - Street 1:700 SHADOW LANE
Practice Address - Street 2:SUITE #165
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106
Practice Address - Country:US
Practice Address - Phone:702-522-9640
Practice Address - Fax:702-522-9641
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6945207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019252Medicaid
F34461Medicare UPIN
F34461Medicare UPIN