MEDICARE: DR. RUPERTO RICARDO MARTINEZ PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	426	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00NM00L240	OTHER	NM	BLUE CROSS-BLUE SHIELD
2	20089	OTHER	NM	PRESBYTERIANHEALTH PLAN

General Provider Information

NPI Number	:	1073695615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUPERTO RICARDO MARTINEZ PHD

Provider Business Mailing Address
First Line	:	5120 VISTA DE LUZ DR NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-1907
Country	:	US
Telephone Number	:	505-899-2620
Fax Number	:	505-897-2199

Provider Business Practice Location Address
First Line	:	5120 VISTA DE LUZ DR NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-1907
Country	:	US
Telephone Number	:	505-899-2620
Fax Number	:	505-897-2199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. RUPERTO RICARDO MARTINEZ PHD” Practice Location

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