Healthcare Provider Details

I. General information

NPI: 1265019392
Provider Name (Legal Business Name): IVAN MARTINEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA195722
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: