Healthcare Provider Details

I. General information

NPI: 1760226294
Provider Name (Legal Business Name): GILDARDO MARTINEZ JUAREZ RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N BROADWAY
GREEN BAY WI
54303-3426
US

IV. Provider business mailing address

424 S MONROE AVE
GREEN BAY WI
54301-4054
US

V. Phone/Fax

Practice location:
  • Phone: 920-863-9356
  • Fax:
Mailing address:
  • Phone: 920-437-7206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number5101-29
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: