MEDICARE: GUSTAVO R MARTINEZ

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	1041C0700X	Clinical Social Worker	01545	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	88048Q	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154397651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUSTAVO R MARTINEZ

Provider Business Mailing Address
First Line	:	814 MYRTLE AVE
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79901-1512
Country	:	US
Telephone Number	:	915-241-7272
Fax Number	:	877-587-9452

Provider Business Practice Location Address
First Line	:	814 MYRTLE AVE
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79901-1512
Country	:	US
Telephone Number	:	915-241-7272
Fax Number	:	877-587-9452

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

Provider Enumeration Date	:	02/24/2006
Last Update Date	:	11/14/2009

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Directions to “ GUSTAVO R MARTINEZ ” Practice Location

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