Healthcare Provider Details

I. General information

NPI: 1114118676
Provider Name (Legal Business Name): JUAN CARLOS MARTINEZ-MORENO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3017 W CHARLESTON BLVD SUITE 90
LAS VEGAS NV
89102-1941
US

IV. Provider business mailing address

3017 W CHARLESTON BLVD SUITE 90
LAS VEGAS NV
89102-1941
US

V. Phone/Fax

Practice location:
  • Phone: 702-826-2816
  • Fax: 702-826-2813
Mailing address:
  • Phone: 702-826-2816
  • Fax: 702-826-2813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number16826
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: