Provider Demographics
NPI:1538410782
Name:MARTIN, SITA
Entity type:Individual
Prefix:MRS
First Name:SITA
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23331 EL TORO RD
Mailing Address - Street 2:213
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4891
Mailing Address - Country:US
Mailing Address - Phone:949-231-0959
Mailing Address - Fax:949-258-8618
Practice Address - Street 1:388 W BAY ST
Practice Address - Street 2:3
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2048
Practice Address - Country:US
Practice Address - Phone:949-231-0959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor