Provider Demographics
NPI:1346420171
Name:MARTINEZ, CARMEN (MD)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14358 SANDY HOOK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2827
Mailing Address - Country:US
Mailing Address - Phone:904-285-1660
Mailing Address - Fax:
Practice Address - Street 1:6410 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-2813
Practice Address - Country:US
Practice Address - Phone:904-493-6967
Practice Address - Fax:904-425-7259
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL46639207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045329300Medicaid