Healthcare Provider Details

I. General information

NPI: 1174574982
Provider Name (Legal Business Name): JAMES RAY MARTIN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S GRAND AVE
LOS ANGELES CA
90015-3048
US

IV. Provider business mailing address

4161 REDONDO BEACH BLVD SUITE 201
LAWNDALE CA
90260-3306
US

V. Phone/Fax

Practice location:
  • Phone: 213-765-7500
  • Fax: 213-765-7390
Mailing address:
  • Phone: 310-214-8677
  • Fax: 310-921-1718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA11973
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: