Provider Demographics
NPI:1164010443
Name:MARTINEZ OLIVA, JUAN M
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:M
Last Name:MARTINEZ OLIVA
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 1:8865 COMMODITY CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-9077
Mailing Address - Country:US
Mailing Address - Phone:321-240-8210
Mailing Address - Fax:
Practice Address - Street 1:8865 COMMODITY CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9077
Practice Address - Country:US
Practice Address - Phone:321-240-8210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL237018376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL237018Medicaid