Healthcare Provider Details

I. General information

NPI: 1659574226
Provider Name (Legal Business Name): LISA C. MARTINEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N MILITARY TRL SUITE 260
BOCA RATON FL
33431-6344
US

IV. Provider business mailing address

2500 N MILITARY TRL SUITE 260
BOCA RATON FL
33431-6344
US

V. Phone/Fax

Practice location:
  • Phone: 561-886-1202
  • Fax: 561-866-1200
Mailing address:
  • Phone: 561-886-1202
  • Fax: 561-866-1200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME115971
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116019236
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101248823
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number0101248823
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: