=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093974909
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TERRIN E. MARTIN, M.D., A MEDICAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2008
-----------------------------------------------------
Last Update Date | 02/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1411 N DETROIT ST #103
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-4488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-482-8550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1411 N DETROIT ST #103
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-4488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-482-8550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TERRIN E MARTIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-482-8550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | A99078
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------