Healthcare Provider Details

I. General information

NPI: 1639244064
Provider Name (Legal Business Name): MYRA C. MARTIN, M.D., APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9449 SAN FERNANDO RD
SUN VALLEY CA
91352-1421
US

IV. Provider business mailing address

PO BOX 7001
TARZANA CA
91357-7001
US

V. Phone/Fax

Practice location:
  • Phone: 818-252-2231
  • Fax:
Mailing address:
  • Phone: 818-888-7815
  • Fax: 818-715-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA904109
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA904109
License Number StateCA

VIII. Authorized Official

Name: MYRA MARTIN
Title or Position: PRESIDENT- SOLE OWNER
Credential: M.D.
Phone: 818-888-7815