Healthcare Provider Details

I. General information

NPI: 1013572262
Provider Name (Legal Business Name): LAURA ENID MARTINEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 RIBBON FALLS PKWY
ORLANDO FL
32824
US

IV. Provider business mailing address

2131 RIBBON FALLS PKWY
ORLANDO FL
32824-4305
US

V. Phone/Fax

Practice location:
  • Phone: 407-779-3596
  • Fax: 407-850-0090
Mailing address:
  • Phone: 407-779-3596
  • Fax: 407-850-0090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberM635525795910
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: