Healthcare Provider Details

I. General information

NPI: 1154352417
Provider Name (Legal Business Name): JOHN RAY MARTINEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SKAGGS RD SUITE 302
BRANSON MO
65616-2075
US

IV. Provider business mailing address

101 SKAGGS RD SUITE 302
BRANSON MO
65616-2075
US

V. Phone/Fax

Practice location:
  • Phone: 417-334-8288
  • Fax: 417-334-6966
Mailing address:
  • Phone: 417-334-8288
  • Fax: 417-334-6966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberR2G43
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: