Provider Demographics
NPI:1720162969
Name:MARTIN, DIANNE C (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANNE
Middle Name:C
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2287 MOWRY AVE STE F
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1622
Mailing Address - Country:US
Mailing Address - Phone:510-248-1585
Mailing Address - Fax:510-739-1050
Practice Address - Street 1:2287 MOWRY AVE STE F
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1622
Practice Address - Country:US
Practice Address - Phone:510-248-1585
Practice Address - Fax:510-739-1050
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG045774207RI0200X
CAG45774207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG045774OtherSTATE OF CALIFORNIA