Provider Demographics
NPI:1093825259
Name:MARTINEZ, KENNETH PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PATRICK
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 JOURNEY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5336
Mailing Address - Country:US
Mailing Address - Phone:949-305-7122
Mailing Address - Fax:949-305-7160
Practice Address - Street 1:5 JOURNEY
Practice Address - Street 2:SUITE 210
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5336
Practice Address - Country:US
Practice Address - Phone:949-305-7122
Practice Address - Fax:949-305-7160
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0616394522084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH49042Medicare UPIN
CAWA66709BMedicare ID - Type Unspecified