Healthcare Provider Details

I. General information

NPI: 1073703682
Provider Name (Legal Business Name): JUDITH ANN MARTIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 07/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 INTERNATIONAL BLVD
OAKLAND CA
94606-4331
US

IV. Provider business mailing address

1124 INTERNATIONAL BLVD
OAKLAND CA
94606-4331
US

V. Phone/Fax

Practice location:
  • Phone: 510-533-0800
  • Fax: 510-898-2183
Mailing address:
  • Phone: 510-533-0800
  • Fax: 510-898-2183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG38355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: