MEDICARE: DR. GONZALO MARTINEZ JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	13580	AZ

General Provider Information

NPI Number	:	1578800439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GONZALO MARTINEZ JR. MD

Provider Business Mailing Address
First Line	:	2554 MORGAN CITY AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-7118
Country	:	US
Telephone Number	:	702-616-3966
Fax Number	:	702-616-3966

Provider Business Practice Location Address
First Line	:	2554 MORGAN CITY AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-7118
Country	:	US
Telephone Number	:	702-616-3966
Fax Number	:	702-616-3966

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2013
Last Update Date	:	01/12/2013

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