Provider Demographics
NPI:1912914359
Name:WAREHAM, MARTIN EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:EDWARD
Last Name:WAREHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S MOORPARK RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1008
Mailing Address - Country:US
Mailing Address - Phone:805-379-9646
Mailing Address - Fax:805-379-0611
Practice Address - Street 1:2876 SYCAMORE DR
Practice Address - Street 2:STE 303
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1550
Practice Address - Country:US
Practice Address - Phone:805-379-9646
Practice Address - Fax:805-379-0611
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37934207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00957558OtherMEDICARE RAILROAD
CAP00957558OtherMEDICARE RAILROAD
CAA47292Medicare UPIN
CAA47292Medicare PIN
CAER292ZMedicare PIN
CAG37934BMedicare PIN