Provider Demographics
NPI:1801098967
Name:EPSON, MARTIN FITZGERALD (MD, JD, MTS)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:FITZGERALD
Last Name:EPSON
Suffix:
Gender:M
Credentials:MD, JD, MTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1569 SOLANO AVE # 401
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94707-2116
Mailing Address - Country:US
Mailing Address - Phone:415-473-2100
Mailing Address - Fax:
Practice Address - Street 1:240 TAMAL VISTA BLVD
Practice Address - Street 2:#160
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925
Practice Address - Country:US
Practice Address - Phone:415-473-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD292562084P0800X
CODR.00515142084P0800X
CA1327232084P0802X, 2084P0800X, 2084F0202X, 2084P0015X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21956260Medicaid
CO21956260Medicaid