Healthcare Provider Details

I. General information

NPI: 1528236981
Provider Name (Legal Business Name): ANTONIO MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1983 MARENGO ST DEM
LOS ANGELES CA
90033-1370
US

IV. Provider business mailing address

4111 MAINE AVE
BALDWIN PARK CA
91706-3307
US

V. Phone/Fax

Practice location:
  • Phone: 323-369-0955
  • Fax:
Mailing address:
  • Phone: 323-369-0955
  • Fax: 626-517-5482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: