Healthcare Provider Details

I. General information

NPI: 1023014800
Provider Name (Legal Business Name): IVAN P MARTINEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S ANAHEIM HILLS RD STE 200
ANAHEIM HILLS CA
92807-4759
US

IV. Provider business mailing address

500 S ANAHEIM HILLS RD STE 200
ANAHEIM HILLS CA
92807-4759
US

V. Phone/Fax

Practice location:
  • Phone: 714-974-1717
  • Fax: 714-974-9019
Mailing address:
  • Phone: 714-974-1717
  • Fax: 714-974-9019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberA258660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: