Provider Demographics
NPI:1083179568
Name:MARTINEZ, MARY GLORIA
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:GLORIA
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:
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 640726
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-0726
Mailing Address - Country:US
Mailing Address - Phone:915-474-3537
Mailing Address - Fax:915-755-7191
Practice Address - Street 1:8933 ANKERSON ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79904-1320
Practice Address - Country:US
Practice Address - Phone:915-629-2079
Practice Address - Fax:915-755-7191
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX012684251E00000X, 3747P1801X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1669646402Medicaid