Provider Demographics
NPI:1114219524
Name:MARTINEZ, RAISA C (MD)
Entity Type:Individual
Prefix:
First Name:RAISA
Middle Name:C
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:677 CHURCH ST NE STE 100
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1101
Mailing Address - Country:US
Mailing Address - Phone:770-422-2326
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE # MC2030
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-702-0151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361375852084N0400X
GA0809422084A2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology