Healthcare Provider Details

I. General information

NPI: 1093825259
Provider Name (Legal Business Name): KENNETH PATRICK MARTINEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 09/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 JOURNEY SUITE 210
ALISO VIEJO CA
92656-5336
US

IV. Provider business mailing address

5 JOURNEY SUITE 210
ALISO VIEJO CA
92656-5336
US

V. Phone/Fax

Practice location:
  • Phone: 949-305-7122
  • Fax: 949-305-7160
Mailing address:
  • Phone: 949-305-7122
  • Fax: 949-305-7160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number061639452
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: