Healthcare Provider Details

I. General information

NPI: 1376001503
Provider Name (Legal Business Name): VANESSA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 NW 16TH ST
MIAMI FL
33125-1624
US

IV. Provider business mailing address

17275 COLLINS AVE APT 505
SUNNY ISLES BEACH FL
33160-3443
US

V. Phone/Fax

Practice location:
  • Phone: 305-575-7000
  • Fax:
Mailing address:
  • Phone: 786-537-6595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number175162
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: