Provider Demographics
NPI:1679352496
Name:MARTINEZ GOMEZ, LUIS ENRIQUE
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ENRIQUE
Last Name:MARTINEZ GOMEZ
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 1:7861 NW 174TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-3619
Mailing Address - Country:US
Mailing Address - Phone:786-669-9148
Mailing Address - Fax:
Practice Address - Street 1:7861 NW 174TH TER
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-3619
Practice Address - Country:US
Practice Address - Phone:786-669-9148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-299609106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician