=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144759895
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON RYAN MARTINEZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2017
-----------------------------------------------------
Last Update Date | 09/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 OLD LANCASTER RD STE 250
-----------------------------------------------------
City | BRYN MAWR
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19010-3239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-565-8564
-----------------------------------------------------
Fax | 610-565-3046
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3803 W CHESTER PIKE STE 160
-----------------------------------------------------
City | NEWTOWN SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19073-2336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-337-1632
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | MD489104
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | MT213925
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------