Provider Demographics
NPI:1174566566
Name:MARTIN, W RANDY (MD)
Entity type:Individual
Prefix:
First Name:W
Middle Name:RANDY
Last Name:MARTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WALTER
Other - Middle Name:RANDOLPH
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3637 MISSION AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2946
Mailing Address - Country:US
Mailing Address - Phone:916-786-7498
Mailing Address - Fax:916-786-2715
Practice Address - Street 1:5 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 190
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2865
Practice Address - Country:US
Practice Address - Phone:916-786-7498
Practice Address - Fax:916-786-2715
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55146207RI0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G551460Medicaid
CAA52879Medicare UPIN
CA00G551461Medicare PIN