Provider Demographics
NPI:1023211711
Name:MARTINEZ, EDIN
Entity Type:Individual
Prefix:MR
First Name:EDIN
Middle Name:
Last Name:MARTINEZ
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 1:5425 N 80TH LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303-5517
Mailing Address - Country:US
Mailing Address - Phone:623-872-9122
Mailing Address - Fax:
Practice Address - Street 1:5425 N 80TH LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-5517
Practice Address - Country:US
Practice Address - Phone:623-872-9122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9305171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor