Provider Demographics
NPI:1609514629
Name:MARTINEZ, MODESTO ALONZO
Entity Type:Individual
Prefix:
First Name:MODESTO
Middle Name:ALONZO
Last Name:MARTINEZ
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 1:14203 BUSINESS AVE
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-7909
Mailing Address - Country:US
Mailing Address - Phone:956-744-1264
Mailing Address - Fax:
Practice Address - Street 1:14203 BUSINESS AVE
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-7909
Practice Address - Country:US
Practice Address - Phone:956-744-1264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11650142OtherTEXAS DL