Healthcare Provider Details

I. General information

NPI: 1710478284
Provider Name (Legal Business Name): STEPHANIE MARTINEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 GRAND CONCOURSE
BRONX NY
10453-4317
US

IV. Provider business mailing address

234 EUGENIO MARIA DE HOSTO BLVD
BRONX NY
10451-5504
US

V. Phone/Fax

Practice location:
  • Phone: 718-220-2020
  • Fax: 718-220-2020
Mailing address:
  • Phone: 718-579-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number311430
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: