Provider Demographics
NPI:1043240864
Name:MARTINEZ, MARIO ITALO (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ITALO
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 734812
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4812
Mailing Address - Country:US
Mailing Address - Phone:210-358-9500
Mailing Address - Fax:210-358-9183
Practice Address - Street 1:302 DORA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-1516
Practice Address - Country:US
Practice Address - Phone:210-358-8255
Practice Address - Fax:210-644-8025
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD12082208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics