Provider Demographics
NPI:1780679779
Name:MARTIN, DONALD PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:PATRICK
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:530-542-5740
Mailing Address - Fax:530-542-5743
Practice Address - Street 1:1108 4TH STREET
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:530-542-5740
Practice Address - Fax:530-542-5743
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA063596207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G85377Medicare UPIN
00A635960Medicare ID - Type Unspecified