Healthcare Provider Details

I. General information

NPI: 1285239962
Provider Name (Legal Business Name): JUAN CARLOS MARTINEZ ZEGARRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 STOCKHOLM ST
BROOKLYN NY
11237-4006
US

IV. Provider business mailing address

PO BOX 370627
BROOKLYN NY
11237-0627
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-7189
  • Fax:
Mailing address:
  • Phone: 503-334-5904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number105740-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: