Basic Information
| Provider Information | |||||||||
| NPI: | 1295925360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | GERARDO | ||||||||
| MiddleName: | BURGOS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1824 JAKE MILLS CT | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921147829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194714372 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1824 JAKE MILLS CT | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921147829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194714372 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 07/25/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A100776 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.