Healthcare Provider Details

I. General information

NPI: 1063045193
Provider Name (Legal Business Name): MR. DEMINFER J MEJIAS MARTINEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 02/17/2020
Certification Date: 02/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7355 BIMINI LN APT D
INDIANAPOLIS IN
46214-1108
US

IV. Provider business mailing address

7355 BIMINI LN APT D
INDIANAPOLIS IN
46214-1108
US

V. Phone/Fax

Practice location:
  • Phone: 786-862-0893
  • Fax:
Mailing address:
  • Phone: 786-862-0893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberM225170914130
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: