Provider Demographics
NPI:1669416186
Name:MARTIN, JOHN SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SAMUEL
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0556
Mailing Address - Country:US
Mailing Address - Phone:209-571-6622
Mailing Address - Fax:209-527-2069
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-577-4444
Practice Address - Fax:209-527-2069
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG331752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G331750Medicaid
CA00G331755Medicare PIN
CAA45451Medicare UPIN
CA00G3317513Medicare PIN
CA00G331754Medicare PIN
CA00G3317510Medicare PIN
CA00G331751Medicare PIN
CA00G3317511Medicare PIN
CA00G331756Medicare PIN
CA300024669Medicare PIN
CA00G331750Medicaid
CA00G3317515Medicare PIN
CA00G331758Medicare PIN
CA00G331753Medicare PIN
CA00G331757Medicare PIN
CA00G331752Medicare PIN
CA00G3317512Medicare PIN
CA00G331759Medicare PIN