Provider Demographics
NPI:1659574226
Name:MARTINEZ, LISA C (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N MILITARY TRL
Mailing Address - Street 2:SUITE 260
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6344
Mailing Address - Country:US
Mailing Address - Phone:561-886-1202
Mailing Address - Fax:561-866-1200
Practice Address - Street 1:2500 N MILITARY TRL
Practice Address - Street 2:SUITE 260
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6344
Practice Address - Country:US
Practice Address - Phone:561-886-1202
Practice Address - Fax:561-866-1200
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115971207R00000X
VA0116019236390200000X
VA0101248823207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1659574226Medicaid
VAVV0256AMedicare PIN