Healthcare Provider Details

I. General information

NPI: 1194726943
Provider Name (Legal Business Name): JILLIAN ROSE MARTIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST FSSG, MSSG 15 BOX 555717
CAMP PENDLETON CA
92055-5717
US

IV. Provider business mailing address

780 W G ST 369
SAN DIEGO CA
92101-5902
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-3785
  • Fax:
Mailing address:
  • Phone: 619-994-2352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01058347A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: