MEDICARE: LIDICE 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	225700000X	Massage Therapist	MA53483	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA53483	OTHER	FL	LICENSED MEDICAL PRACTITIONER

General Provider Information

NPI Number	:	1366088569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIDICE MARTINEZ

Provider Business Mailing Address
First Line	:	2422 WOODY TRACE LN
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33612-7121
Country	:	US
Telephone Number	:	813-325-0139
Fax Number	:

Provider Business Practice Location Address
First Line	:	2422 WOODY TRACE LN
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33612-7121
Country	:	US
Telephone Number	:	813-325-0139
Fax Number	:

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

Provider Enumeration Date	:	11/22/2019
Last Update Date	:	11/22/2019

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Directions to “ LIDICE MARTINEZ ” Practice Location

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