Basic Information
| Provider Information | |||||||||
| NPI: | 1356454086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | TANDOC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 DOYLE PARK DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075446090 | ||||||||
| FaxNumber: | 7075442389 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 MONTGOMERY DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7073038321 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | A83664 | CA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | A83664 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GR0061380 | 05 | CA | MEDICAID |