Provider Demographics
NPI:1225227754
Name:LYNORE M MARTINEZ MD PROFESSIONAL ASSOCIATION
Entity Type:Organization
Organization Name:LYNORE M MARTINEZ MD PROFESSIONAL ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNORE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-988-4922
Mailing Address - Street 1:405 KIVA CT
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-988-4922
Mailing Address - Fax:505-988-4924
Practice Address - Street 1:405 KIVA CT
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-988-4922
Practice Address - Fax:505-988-4924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95294174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM009T01OtherBLUE CROSS
NM00068674Medicaid
NM00068674Medicaid