Provider Demographics
NPI:1629071501
Name:RILEY, MARTINA (DO)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:
Last Name:RILEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 CALLE ENSUENO
Mailing Address - Street 2:
Mailing Address - City:MARATHON
Mailing Address - State:FL
Mailing Address - Zip Code:33050-2503
Mailing Address - Country:US
Mailing Address - Phone:305-743-6073
Mailing Address - Fax:305-743-6073
Practice Address - Street 1:90 CALLE ENSUENO
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:FL
Practice Address - Zip Code:33050-2503
Practice Address - Country:US
Practice Address - Phone:305-743-6073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8535207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00019417OtherRAILROAD
FL71247OtherBLUECROSS BLUESHIELD
P00019417OtherRAILROAD
FLU0632ZMedicare PIN