Healthcare Provider Details

I. General information

NPI: 1336635838
Provider Name (Legal Business Name): ANTONIO MANUEL MARTINEZ GARCIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 E 58TH ST
HIALEAH FL
33013-1244
US

IV. Provider business mailing address

152 E 58TH ST
HIALEAH FL
33013-1244
US

V. Phone/Fax

Practice location:
  • Phone: 305-326-3288
  • Fax:
Mailing address:
  • Phone: 305-326-3288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9417810
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number9417810
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: