Provider Demographics
NPI:1134543408
Name:MARTIN, ROD
Entity type:Individual
Prefix:
First Name:ROD
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 HARBOR BAY PKWY
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502-6501
Mailing Address - Country:US
Mailing Address - Phone:510-780-3163
Mailing Address - Fax:510-864-5254
Practice Address - Street 1:1220 HARBOR BAY PKWY
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94502-6501
Practice Address - Country:US
Practice Address - Phone:510-780-3163
Practice Address - Fax:510-864-5254
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist