Provider Demographics
NPI:1689782294
Name:MARTINEZ, CARLOS ROBERTO (IDC)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ROBERTO
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829B TERRIER STREET
Mailing Address - Street 2:
Mailing Address - City:POINT MUGU
Mailing Address - State:CA
Mailing Address - Zip Code:93041
Mailing Address - Country:US
Mailing Address - Phone:805-889-5848
Mailing Address - Fax:
Practice Address - Street 1:161 1ST ST
Practice Address - Street 2:BLDG 1402
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-0001
Practice Address - Country:US
Practice Address - Phone:805-982-6496
Practice Address - Fax:805-815-3753
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman