Provider Demographics
NPI:1033293238
Name:MARTINEZ, SUSAN (OD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 E MORTON PL
Mailing Address - Street 2:STE A
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4534
Mailing Address - Country:US
Mailing Address - Phone:951-929-2746
Mailing Address - Fax:951-346-4060
Practice Address - Street 1:999 E MORTON PL
Practice Address - Street 2:STE A
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4534
Practice Address - Country:US
Practice Address - Phone:951-929-2746
Practice Address - Fax:951-346-4060
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10117T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARGSD004570Medicaid
CASD0101170Medicaid
CAU44547Medicare UPIN
CASD0101170Medicaid