MEDICARE: MARTIN S WASSERMAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0804X	Child & Adolescent Psychiatry Physician	G13282	CA

General Provider Information

NPI Number	:	1134125180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTIN S WASSERMAN M.D.

Provider Business Mailing Address
First Line	:	510 E CHANNEL RD
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90402-1342
Country	:	US
Telephone Number	:	310-454-8870
Fax Number	:	310-573-9696

Provider Business Practice Location Address
First Line	:	510 E CHANNEL RD
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90402-1342
Country	:	US
Telephone Number	:	310-454-8870
Fax Number	:	310-573-9696

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	08/06/2009

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