Provider Demographics
NPI:1952482747
Name:MARTIN, ROBERT EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EUGENE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:E
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2522 GRAND CANAL BLVD
Mailing Address - Street 2:#1
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8213
Mailing Address - Country:US
Mailing Address - Phone:209-951-4666
Mailing Address - Fax:209-951-5829
Practice Address - Street 1:2522 GRAND CANAL BLVD
Practice Address - Street 2:#1
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8213
Practice Address - Country:US
Practice Address - Phone:209-951-4666
Practice Address - Fax:209-951-5829
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
A37227Medicare UPIN
00C398160Medicare ID - Type Unspecified