Healthcare Provider Details

I. General information

NPI: 1093885113
Provider Name (Legal Business Name): EDGAR IVAN MARTINEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3445 PACIFIC COAST HWY STE 110
TORRANCE CA
90505-6659
US

IV. Provider business mailing address

PO BOX 3129
TORRANCE CA
90510-3129
US

V. Phone/Fax

Practice location:
  • Phone: 310-325-4555
  • Fax:
Mailing address:
  • Phone: 310-792-3914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberK6128
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: