Provider Demographics
NPI:1003817131
Name:MARTINEZ, LISA MANUELA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MANUELA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:MANUELA
Other - Last Name:KILBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:110 S PACA ST
Mailing Address - Street 2:SIXTH FLOOR, SUITE 200
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1642
Mailing Address - Country:US
Mailing Address - Phone:410-328-8025
Mailing Address - Fax:410-328-8028
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054704207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD841400900Medicaid
MDP00373208Medicare PIN
226L326YMedicare ID - Type Unspecified
G94382Medicare UPIN
MDO612Medicare PIN