Healthcare Provider Details

I. General information

NPI: 1427178680
Provider Name (Legal Business Name): WANSOON LEE MARTIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WANDA LEIGH MARTIN MD

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10850 WILSHIRE BLVD SUITE 1150
LOS ANGELES CA
90024-4305
US

IV. Provider business mailing address

10850 WILSHIRE BLVD SUITE 1150
LOS ANGELES CA
90024-4305
US

V. Phone/Fax

Practice location:
  • Phone: 310-470-7100
  • Fax: 310-470-7110
Mailing address:
  • Phone: 310-470-7100
  • Fax: 310-470-7110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA51704
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA051704
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: