Provider Demographics
NPI:1275564700
Name:MCKEITHAN, MARTINEZ (HS1)
Entity Type:Individual
Prefix:MR
First Name:MARTINEZ
Middle Name:
Last Name:MCKEITHAN
Suffix:
Gender:M
Credentials:HS1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WOODWARD AVE
Mailing Address - Street 2:COMMANDER USCG SECTOR LONG ISLAND SOUND
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512
Mailing Address - Country:US
Mailing Address - Phone:203-468-4593
Mailing Address - Fax:203-468-4483
Practice Address - Street 1:120 WOODWARD AVE
Practice Address - Street 2:COMMANDER USCG SECTOR LONG ISLAND SOUND
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06512-3628
Practice Address - Country:US
Practice Address - Phone:203-468-4593
Practice Address - Fax:203-468-4483
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other