Provider Demographics
NPI:1689229478
Name:MARTINEZ, MARIO GENARO JR
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:GENARO
Last Name:MARTINEZ
Suffix:JR
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 1:11302 FLORA SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2409
Mailing Address - Country:US
Mailing Address - Phone:813-330-8886
Mailing Address - Fax:
Practice Address - Street 1:11302 FLORA SPRINGS DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-2409
Practice Address - Country:US
Practice Address - Phone:813-330-8886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM63540820472172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver