Provider Demographics
NPI:1326456120
Name:CHAVEZ, MARIO ALFREDO MARTINEZ
Entity Type:Individual
Prefix:
First Name:MARIO ALFREDO
Middle Name:MARTINEZ
Last Name:CHAVEZ
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 1:700 N ALEXANDER ST
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-2002
Mailing Address - Country:US
Mailing Address - Phone:818-970-9258
Mailing Address - Fax:
Practice Address - Street 1:1225 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1901
Practice Address - Country:US
Practice Address - Phone:213-977-2423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000992363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner