Provider Demographics
NPI:1689292617
Name:MARTINEZ, LAZARO I SR
Entity Type:Individual
Prefix:
First Name:LAZARO
Middle Name:I
Last Name:MARTINEZ
Suffix:SR
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 1:800 N 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-7424
Mailing Address - Country:US
Mailing Address - Phone:786-282-0667
Mailing Address - Fax:
Practice Address - Street 1:800 N 69TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-7424
Practice Address - Country:US
Practice Address - Phone:786-282-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-123236106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106S00000XMedicaid