Healthcare Provider Details

I. General information

NPI: 1740625292
Provider Name (Legal Business Name): ELIZABETH GRACE MARTINEZ D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8761
US

IV. Provider business mailing address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8761
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-5700
  • Fax: 559-353-5708
Mailing address:
  • Phone: 559-353-5700
  • Fax: 559-353-5708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number12204
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207ZP0213X
TaxonomyPediatric Pathology Physician
License Number20A17684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: