Provider Demographics
NPI:1497849483
Name:MARTINEZ, FREDERICK CARL (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:CARL
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 4190
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-4190
Mailing Address - Country:US
Mailing Address - Phone:304-399-4405
Mailing Address - Fax:304-399-2526
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:OPC SUITE 230
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702
Practice Address - Country:US
Practice Address - Phone:304-525-3711
Practice Address - Fax:304-525-2748
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19638208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0130543001Medicaid
WV51D2006880OtherCLIA NUMBER
POO762565Medicare PIN
MA0896836Medicare PIN
WV51D2006880OtherCLIA NUMBER
E13976Medicare UPIN