1306886304 NPI number — MICHAEL MARTELLI D.O.

Table of content: MICHAEL MARTELLI D.O. (NPI 1306886304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306886304 NPI number — MICHAEL MARTELLI D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTELLI
Provider First Name:
MICHAEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306886304
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4849 RONSON CT
Provider Second Line Business Mailing Address:
STE 217
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92111-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-279-1212
Provider Business Mailing Address Fax Number:
858-279-1420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 N EL CIELO RD STE D-402
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM SPRINGS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92262-6972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-650-6729
Provider Business Practice Location Address Fax Number:
760-775-5604
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  20A4955 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00AX49550 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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