Provider Demographics
NPI:1043798762
Name:MARTINEZ, JUAN
Entity Type:Individual
Prefix:MR
First Name:JUAN
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 1:4510 SW MALCOM RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-8053
Mailing Address - Country:US
Mailing Address - Phone:580-713-1497
Mailing Address - Fax:
Practice Address - Street 1:602 SW 38TH ST
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6912
Practice Address - Country:US
Practice Address - Phone:580-248-5780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200786490AMedicaid