Provider Demographics
NPI:1215377924
Name:MARTINEZ, JOSE MODESTO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MODESTO
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 1:5550 PAINTED MIRAGE RD STE 320
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-4584
Mailing Address - Country:US
Mailing Address - Phone:702-900-8666
Mailing Address - Fax:
Practice Address - Street 1:5550 PAINTED MIRAGE RD STE 320
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4584
Practice Address - Country:US
Practice Address - Phone:702-900-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional