Provider Demographics
NPI:1659753952
Name:MARTINEZ, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
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 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-0887
Mailing Address - Fax:
Practice Address - Street 1:10 MISSILE AVE
Practice Address - Street 2:
Practice Address - City:MINOT AFB
Practice Address - State:ND
Practice Address - Zip Code:58705-5003
Practice Address - Country:US
Practice Address - Phone:701-723-5491
Practice Address - Fax:701-723-5391
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC38529208600000X
NE29746208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208600000XAllopathic & Osteopathic PhysiciansSurgery