Provider Demographics
NPI:1356009971
Name:MARTINEZ, DERRICK
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:MARTINEZ
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 1:275 LAKE VILLAGE DR APT 306
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-6542
Mailing Address - Country:US
Mailing Address - Phone:512-552-5170
Mailing Address - Fax:
Practice Address - Street 1:2995 E GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3133
Practice Address - Country:US
Practice Address - Phone:512-552-5170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program