Healthcare Provider Details

I. General information

NPI: 1023351889
Provider Name (Legal Business Name): CHRISTINA SOUTHER MARTIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINA SOUTHER MD

II. Dates (important events)

Enumeration Date: 03/30/2013
Last Update Date: 03/14/2025
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N VERMONT AVE #704
LOS ANGELES CA
90027
US

IV. Provider business mailing address

PO BOX 16162
BEVERLY HILLS CA
90209
US

V. Phone/Fax

Practice location:
  • Phone: 310-526-0290
  • Fax: 310-526-0290
Mailing address:
  • Phone: 310-526-0290
  • Fax: 310-526-0290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number19658
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA156794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: