Healthcare Provider Details

I. General information

NPI: 1043240864
Provider Name (Legal Business Name): MARIO ITALO MARTINEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 DORA ST
SAN ANTONIO TX
78212-1516
US

IV. Provider business mailing address

PO BOX 734812
DALLAS TX
75373-4812
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-8255
  • Fax: 210-644-8025
Mailing address:
  • Phone: 210-358-9500
  • Fax: 210-358-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD12082
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: