Healthcare Provider Details

I. General information

NPI: 1487634226
Provider Name (Legal Business Name): LUIS A MARTINEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CONEY ST W
PERHAM MN
56573-2102
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 218-347-1200
  • Fax:
Mailing address:
  • Phone: 605-328-6585
  • Fax: 952-857-1554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number45359
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45359
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: