=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013172733
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY VANN MARTIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2008
-----------------------------------------------------
Last Update Date | 02/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 MOWRY AVE SUITE 212
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94538-1605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-608-6174
-----------------------------------------------------
Fax | 510-745-6435
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7079 HOMEWOOD DR
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94611-1451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PE0004X
-----------------------------------------------------
Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
-----------------------------------------------------
License Number | A23873
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------