Healthcare Provider Details

I. General information

NPI: 1497720023
Provider Name (Legal Business Name): JESS M MARTINEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 DAN PROCTOR DR
SAINT MARYS GA
31558-3810
US

IV. Provider business mailing address

PO BOX 15385
DURHAM NC
27704-0385
US

V. Phone/Fax

Practice location:
  • Phone: 919-477-5152
  • Fax: 919-477-5474
Mailing address:
  • Phone: 919-477-5152
  • Fax: 919-477-5474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number050224
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: