Basic Information
| Provider Information | |||||||||
| NPI: | 1053503516 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONDON | ||||||||
| FirstName: | MARTHA | ||||||||
| MiddleName: | EUGENIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 SUNGLOW DR | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920562528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607260623 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3140 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | CARLSBAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607209898 | ||||||||
| FaxNumber: | 7607297016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2007 | ||||||||
| LastUpdateDate: | 08/17/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | OT 6008 | CA | Y | Other Service Providers | Specialist |
No ID Information.