Provider Demographics
NPI:1013172733
Name:MARTIN, JERRY VANN (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:VANN
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 1:7079 HOMEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-1451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 MOWRY AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1605
Practice Address - Country:US
Practice Address - Phone:510-608-6174
Practice Address - Fax:510-745-6435
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23873207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAP589ZMedicare PIN