Basic Information
| Provider Information | |||||||||
| NPI: | 1174632970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | JOSHUA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 SANTA MONICA BLVD | ||||||||
| Address2: | STE. 540 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105826350 | ||||||||
| FaxNumber: | 3108259482 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 SANTA MONICA BLVD | ||||||||
| Address2: | STE. 540 | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105826350 | ||||||||
| FaxNumber: | 3108259482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ML20008603 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | A107051 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | A107051 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 1174632970 | 05 | CA | MEDICAID | 1174632970 | 01 | CA | CCS PANELED PROVIDER | OTHER |