Provider Demographics
NPI:1376014696
Name:MARTINEZ, JOHNNIE DANIEL
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:DANIEL
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 1:1730 BISHOP ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4691
Mailing Address - Country:US
Mailing Address - Phone:805-781-5352
Mailing Address - Fax:805-781-1230
Practice Address - Street 1:1730 BISHOP ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4691
Practice Address - Country:US
Practice Address - Phone:805-781-5352
Practice Address - Fax:805-781-1230
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-14
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator