Provider Demographics
NPI:1598989238
Name:JESUS A MARTINEZ MD PC
Entity Type:Organization
Organization Name:JESUS A MARTINEZ MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PRACTICE
Authorized Official - Prefix:
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-359-0222
Mailing Address - Street 1:2012 MONROE BLVD SUITE 104
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:313-359-0222
Mailing Address - Fax:
Practice Address - Street 1:2012 MONROE BLVD SUITE 104
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-359-0222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJM031056208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4241325Medicaid
MI=========OtherTAX ID
MI0N18410Medicare ID - Type Unspecified