Healthcare Provider Details

I. General information

NPI: 1699060525
Provider Name (Legal Business Name): NOEL ANTONIO MARTINEZ IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 MASSEY AVE
JACKSONVILLE FL
32228-0148
US

IV. Provider business mailing address

2104 MASSEY AVE
JACKSONVILLE FL
32228-0148
US

V. Phone/Fax

Practice location:
  • Phone: 904-270-4474
  • Fax:
Mailing address:
  • Phone: 904-270-4474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: