Provider Demographics
NPI:1497720023
Name:MARTINEZ, JESS M (MD)
Entity Type:Individual
Prefix:
First Name:JESS
Middle Name:M
Last Name:MARTINEZ
Suffix:
Gender:M
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:PO BOX 15385
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0385
Mailing Address - Country:US
Mailing Address - Phone:919-477-5152
Mailing Address - Fax:919-477-5474
Practice Address - Street 1:2000 DAN PROCTOR DR
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3810
Practice Address - Country:US
Practice Address - Phone:919-477-5152
Practice Address - Fax:919-477-5474
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050224174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA234687OtherBLUE CROSS
GAC34176Medicare UPIN
GA08BBVQNMedicare ID - Type Unspecified