Healthcare Provider Details

I. General information

NPI: 1487610663
Provider Name (Legal Business Name): JEFFREY L MARTINEZ P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 BROADCASTING RD
WYOMISSING PA
19610-3203
US

IV. Provider business mailing address

1270 BROADCASTING RD
WYOMISSING PA
19610-3203
US

V. Phone/Fax

Practice location:
  • Phone: 610-372-1140
  • Fax: 610-372-7684
Mailing address:
  • Phone: 610-372-1140
  • Fax: 610-372-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA003079L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: