Healthcare Provider Details

I. General information

NPI: 1053539015
Provider Name (Legal Business Name): MADELENA MICHELE MARTIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 50TH ST
SACRAMENTO CA
95817-2310
US

IV. Provider business mailing address

2825 50TH ST
SACRAMENTO CA
95817-2310
US

V. Phone/Fax

Practice location:
  • Phone: 916-703-0300
  • Fax: 916-703-0203
Mailing address:
  • Phone: 916-703-0300
  • Fax: 916-703-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number233551
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207SG0202X
TaxonomyClinical Biochemical Genetics Physician
License Number233551
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number233551
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: