Provider Demographics
NPI:1518114131
Name:EDGAR I MARTINEZ DO INC
Entity Type:Organization
Organization Name:EDGAR I MARTINEZ DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:323-582-1180
Mailing Address - Street 1:3512 E FLORENCE AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5900
Mailing Address - Country:US
Mailing Address - Phone:323-582-1180
Mailing Address - Fax:323-582-8280
Practice Address - Street 1:3512 E FLORENCE AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5900
Practice Address - Country:US
Practice Address - Phone:323-582-1180
Practice Address - Fax:323-582-8280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6262208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOAX62622Medicaid
CAOOAX62622Medicaid