Healthcare Provider Details

I. General information

NPI: 1871786335
Provider Name (Legal Business Name): ELLIOTT O MARTINEZ IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2007
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STATE ROAD 108 BLDG 3005 DEWERT BRANCH HEALTH CLINIC
BRIDGEPORT CA
93517-7777
US

IV. Provider business mailing address

S.R. 108 BLDG 3005
BRIDGEPORT CA
93517
US

V. Phone/Fax

Practice location:
  • Phone: 760-932-1616
  • Fax: 760-932-1623
Mailing address:
  • Phone: 760-932-1616
  • Fax: 760-932-1623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: