Provider Demographics
NPI:1639424641
Name:MARTIN, RUDY (PT)
Entity type:Individual
Prefix:MR
First Name:RUDY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2311 ELDEN AVE APT 24
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1590
Mailing Address - Country:US
Mailing Address - Phone:949-244-8328
Mailing Address - Fax:
Practice Address - Street 1:6131 ORANGETHORPE AVE STE 135
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-4901
Practice Address - Country:US
Practice Address - Phone:714-523-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist