Provider Demographics
NPI:1972829232
Name:MARTIN, VICTORIA MACKENZIE (MD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:MACKENZIE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:JEAN
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:175 CAMBRIDGE ST
Mailing Address - Street 2:CPZ 575
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2743
Mailing Address - Country:US
Mailing Address - Phone:617-726-8705
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-8705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2545892080P0206X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology