Healthcare Provider Details

I. General information

NPI: 1255537957
Provider Name (Legal Business Name): KENNETH P MARTINEZ MD A MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 07/21/2022
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 JOURNEY STE 210
ALISO VIEJO CA
92656-5332
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 Number
License Number StateCA

VIII. Authorized Official

Name: KENNETH PATRICK MARTINEZ
Title or Position: NEUROLOGIST
Credential: MD
Phone: 949-305-7122