Healthcare Provider Details

I. General information

NPI: 1750577540
Provider Name (Legal Business Name): NIKKI MARTIN, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 DWIGHT WAY
BERKELEY CA
94704-2608
US

IV. Provider business mailing address

1 BAYWOOD AVE SUITE 7
SAN MATEO CA
94402-1523
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-4405
  • Fax: 510-204-4046
Mailing address:
  • Phone: 650-344-6961
  • Fax: 650-344-6604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA035728
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA035728
License Number StateCA

VIII. Authorized Official

Name: DR. NIKKI LYNN MARTIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 510-467-9156