Provider Demographics
NPI:1134906662
Name:MARTIN, AUDON
Entity type:Individual
Prefix:
First Name:AUDON
Middle Name:
Last Name:MARTIN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 MORENA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3850
Mailing Address - Country:US
Mailing Address - Phone:619-398-0355
Mailing Address - Fax:
Practice Address - Street 1:1260 MORENA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3850
Practice Address - Country:US
Practice Address - Phone:619-398-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-UVJSOC175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist