Healthcare Provider Details

I. General information

NPI: 1225227754
Provider Name (Legal Business Name): LYNORE M MARTINEZ MD PROFESSIONAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2007
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 KIVA CT
SANTA FE NM
87505
US

IV. Provider business mailing address

405 KIVA CT
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-4922
  • Fax: 505-988-4924
Mailing address:
  • Phone: 505-988-4922
  • Fax: 505-988-4924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number95294
License Number StateNM

VIII. Authorized Official

Name: DR. LYNORE M MARTINEZ
Title or Position: OWNER
Credential: MD
Phone: 505-988-4922