Healthcare Provider Details

I. General information

NPI: 1023249059
Provider Name (Legal Business Name): CARMEN SOFIA MARTINEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARMEN SOFIA MARTINEZ VILLAR M.D.

II. Dates (important events)

Enumeration Date: 08/08/2009
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 WINN WAY DEKALB COMMUNITY SERVICE BOARD
DECATUR GA
30030-1707
US

IV. Provider business mailing address

445 WINN WAY DEKALB COMMUNITY SERVICE BOARD
DECATUR GA
30030-1707
US

V. Phone/Fax

Practice location:
  • Phone: 404-508-7700
  • Fax:
Mailing address:
  • Phone: 404-508-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number67826
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: