MEDICARE: MR. PETER DAVID MARTZ ATC, LAT

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	2255A2300X	Athletic Trainer	AL230	FL

General Provider Information

NPI Number	:	1205892429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETER DAVID MARTZ ATC, LAT

Provider Business Mailing Address
First Line	:	6840 SW 10TH ST
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33023-1633
Country	:	US
Telephone Number	:	954-986-9150
Fax Number	:

Provider Business Practice Location Address
First Line	:	1050 NW 195TH ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33169-3040
Country	:	US
Telephone Number	:	305-653-1416
Fax Number	:

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

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	07/08/2007

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