Healthcare Provider Details

I. General information

NPI: 1073695615
Provider Name (Legal Business Name): RUPERTO RICARDO MARTINEZ PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 VISTA DE LUZ DR NW
ALBUQUERQUE NM
87120-1907
US

IV. Provider business mailing address

5120 VISTA DE LUZ DR NW
ALBUQUERQUE NM
87120-1907
US

V. Phone/Fax

Practice location:
  • Phone: 505-899-2620
  • Fax: 505-897-2199
Mailing address:
  • Phone: 505-899-2620
  • Fax: 505-897-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number426
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: