Provider Demographics
NPI:1225036320
Name:MARTIN, DAVID JOHN (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
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 1:4415 SONOMA HWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-7100
Mailing Address - Country:US
Mailing Address - Phone:707-537-2070
Mailing Address - Fax:707-537-9696
Practice Address - Street 1:4415 SONOMA HWY
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-7100
Practice Address - Country:US
Practice Address - Phone:707-537-2070
Practice Address - Fax:707-537-9696
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82729208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0067920Medicaid
P00051386OtherRR MEDICARD
CA00A827290Medicare PIN
H88323Medicare UPIN
CAGR0067920Medicaid