Provider Demographics
NPI:1790995645
Name:MARTIN S. COUSINEAU M.D. INC.
Entity Type:Organization
Organization Name:MARTIN S. COUSINEAU M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:SHIELDS
Authorized Official - Last Name:COUSINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-557-0049
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:90212-1606
Mailing Address - Country:US
Mailing Address - Phone:310-557-0049
Mailing Address - Fax:
Practice Address - Street 1:450 N ROXBURY DR STE 250
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4240
Practice Address - Country:US
Practice Address - Phone:310-246-4628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50372207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G503720Medicaid
CA00G503720Medicaid
CAG50372Medicare ID - Type Unspecified