Provider Demographics
NPI:1245319862
Name:MARTIN, SUZANNE B (PT)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:B
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3760 CONVOY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-3743
Mailing Address - Country:US
Mailing Address - Phone:858-264-1434
Mailing Address - Fax:858-751-0901
Practice Address - Street 1:552 S PASEO DOROTEA STE 4
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-1437
Practice Address - Country:US
Practice Address - Phone:760-325-5950
Practice Address - Fax:760-325-5945
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22727225100000X
TX1191167225100000X
CA292199225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT22727OtherSTATE LICENSE
TXTXB116253OtherPTAN
FLPT22727OtherSTATE LICENSE