Healthcare Provider Details

I. General information

NPI: 1891794830
Provider Name (Legal Business Name): ENRIQUE C. MARTINEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

3114A SHRINE RD
BRUNSWICK GA
31520-4745
US

IV. Provider business mailing address

3114 A SHRINE ROAD
BRUNSWICK GA
31520-4745
US

V. Phone/Fax

Practice location:
  • Phone: 912-261-2535
  • Fax: 912-261-2508
Mailing address:
  • Phone: 912-261-2535
  • Fax: 912-261-2508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number28603
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: