Provider Demographics
NPI:1275704686
Name:MARTINEZ, MIKE T (CO)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:T
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1925
Mailing Address - Country:US
Mailing Address - Phone:916-488-1478
Mailing Address - Fax:916-488-1807
Practice Address - Street 1:1848 FULTON AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-1925
Practice Address - Country:US
Practice Address - Phone:916-488-1478
Practice Address - Fax:916-488-1807
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACO2798174400000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC00027980OtherBC
CAXA0027980Medicaid
CA0152576OtherKAISER
CAC00027980OtherBLUE CROSS
CA1284760001Medicare NSC