Provider Demographics
NPI:1144589144
Name:MARTINEZ, MARK
Entity Type:Individual
Prefix:
First Name:MARK
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 1:13520 BONA VISTA LN
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-2803
Mailing Address - Country:US
Mailing Address - Phone:562-921-6423
Mailing Address - Fax:
Practice Address - Street 1:13520 BONA VISTA LN
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-2803
Practice Address - Country:US
Practice Address - Phone:562-921-6423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT2847225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant