Healthcare Provider Details

I. General information

NPI: 1154783041
Provider Name (Legal Business Name): LUIS FERNANDO MARTINEZ OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 N ED CAREY DR
HARLINGEN TX
78550-7914
US

IV. Provider business mailing address

1900 S JACKSON RD STE 2&3
MCALLEN TX
78503-1588
US

V. Phone/Fax

Practice location:
  • Phone: 956-440-1155
  • Fax: 956-440-0913
Mailing address:
  • Phone: 956-630-4400
  • Fax: 956-630-4447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number117582
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: