Healthcare Provider Details

I. General information

NPI: 1316920952
Provider Name (Legal Business Name): ALFONSO MARTINEZ PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6000 SHAKERAG HL SUITE 216
PEACHTREE CITY GA
30269-6523
US

IV. Provider business mailing address

406 MOUNT VERNON TRCE
PEACHTREE CITY GA
30269-2641
US

V. Phone/Fax

Practice location:
  • Phone: 770-632-1088
  • Fax: 770-632-2088
Mailing address:
  • Phone: 770-629-4575
  • Fax: 770-629-4575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY5814
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY3117
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: