Provider Demographics
NPI:1003028853
Name:MARTINA, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MARTINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15271 MCGREGOR BLVD STE 17
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-1900
Mailing Address - Country:US
Mailing Address - Phone:239-433-2060
Mailing Address - Fax:239-433-0925
Practice Address - Street 1:15271 MCGREGOR BLVD STE 17
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-1900
Practice Address - Country:US
Practice Address - Phone:239-433-2060
Practice Address - Fax:239-433-0925
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY103231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist