Healthcare Provider Details

I. General information

NPI: 1275638850
Provider Name (Legal Business Name): BRIAN C. MARTIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 CANTON ST SUITE 325
WESTWOOD MA
02090-2321
US

IV. Provider business mailing address

690 CANTON ST STE 325
WESTWOOD MA
02090-2324
US

V. Phone/Fax

Practice location:
  • Phone: 781-407-7713
  • Fax: 781-407-0998
Mailing address:
  • Phone: 781-407-7713
  • Fax: 781-407-0998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number247086
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101237045
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: