Provider Demographics
NPI:1467062018
Name:MARTIN, CARLOS ENRIQUE
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ENRIQUE
Last Name:MARTIN
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 1:6276 NW 186TH ST APT 205
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-6056
Mailing Address - Country:US
Mailing Address - Phone:786-650-5761
Mailing Address - Fax:
Practice Address - Street 1:12989 SW 251ST TER
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5788
Practice Address - Country:US
Practice Address - Phone:786-650-5761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty