MEDICARE: JILLIAN ROSE MARTIN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	01058347A	IN

General Provider Information

NPI Number	:	1194726943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLIAN ROSE MARTIN M.D.

Provider Business Mailing Address
First Line	:	780 W G ST
Second Line	:	369
City	:	SAN DIEGO
State	:	CA
Zip	:	92101-5902
Country	:	US
Telephone Number	:	619-994-2352
Fax Number	:

Provider Business Practice Location Address
First Line	:	1ST FSSG, MSSG 15 BOX 555717
Second Line	:
City	:	CAMP PENDLETON
State	:	CA
Zip	:	92055-5717
Country	:	US
Telephone Number	:	760-725-3785
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	07/08/2007

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