Healthcare Provider Details

I. General information

NPI: 1275985533
Provider Name (Legal Business Name): JUAN CARLOS MARTINEZ GUTIERREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 HOSPITAL BLVD STE 310
ROSWELL GA
30076-4947
US

IV. Provider business mailing address

2500 HOSPITAL BLVD STE 310
ROSWELL GA
30076-4947
US

V. Phone/Fax

Practice location:
  • Phone: 770-664-9600
  • Fax: 770-664-9856
Mailing address:
  • Phone: 770-664-9600
  • Fax: 770-664-9856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number268195
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberS9028
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number96832
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: