Provider Demographics
NPI:1679652796
Name:MARTINEZ, DEOGRACIAS RUFINO JR (MD)
Entity Type:Individual
Prefix:
First Name:DEOGRACIAS
Middle Name:RUFINO
Last Name:MARTINEZ
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DEO
Other - Middle Name:
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-243-8500
Mailing Address - Fax:702-560-2928
Practice Address - Street 1:2704 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0424
Practice Address - Country:US
Practice Address - Phone:702-243-8500
Practice Address - Fax:702-560-2928
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8869207R00000X, 207R00000X
CAA32000207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0021600Medicaid
NV1679652796OtherSMA MEDICAID
NVV108086OtherSMA MEDICARE
NV1679652796OtherSMA MEDICAID
NVV108086Medicare UPIN
00A32000Medicare ID - Type Unspecified