Provider Demographics
NPI:1649442609
Name:MARTIN, MATTHEW LANE (DO)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LANE
Last Name:MARTIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 W OLYMPIC BLVD # 2265
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91199-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:874 AMERICAN PACIFIC DR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-8800
Practice Address - Country:US
Practice Address - Phone:702-777-4809
Practice Address - Fax:702-777-4822
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO1553207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1649442609Medicaid
NVDZ907YMedicare UPIN