=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720202211
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ENRIQUE STANLEY MARTINEZ ONA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 09/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13991 W GRAND AVE STE 105
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-455-7800
-----------------------------------------------------
Fax | 234-557-8306
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10880
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86304-0880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-759-5987
-----------------------------------------------------
Fax | 928-458-2039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5017
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------