MEDICARE: MR. MICHAEL E MARTIN MD

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	207K00000X	Allergy & Immunology Physician	G29076	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G29076	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1245213776
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL E MARTIN MD

Provider Business Mailing Address
First Line	:	2461 SUMMERFIELD RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7815
Country	:	US
Telephone Number	:	707-525-0211
Fax Number	:	707-525-0491

Provider Business Practice Location Address
First Line	:	2461 SUMMERFIELD RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-7815
Country	:	US
Telephone Number	:	707-525-0211
Fax Number	:	707-525-0491

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

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	07/08/2007

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