Healthcare Provider Details

I. General information

NPI: 1528992468
Provider Name (Legal Business Name): DR. LOGAN PAUL MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4051 E FAIRVIEW AVE
MERIDIAN ID
83642-5801
US

IV. Provider business mailing address

4568 S WILDBROOK AVE
BOISE ID
83709-4437
US

V. Phone/Fax

Practice location:
  • Phone: 208-373-0024
  • Fax: 208-373-0784
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberI66760
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: