Healthcare Provider Details

I. General information

NPI: 1972371227
Provider Name (Legal Business Name): MILES SAMUEL MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 5TH ST
MODESTO CA
95351-3316
US

IV. Provider business mailing address

609 5TH ST
MODESTO CA
95351-3316
US

V. Phone/Fax

Practice location:
  • Phone: 916-584-7223
  • Fax: 209-341-0716
Mailing address:
  • Phone: 916-584-7223
  • Fax: 209-341-0716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: