Provider Demographics
NPI:1720593585
Name:MARTINEZ, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:MARTINEZ
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 1:611 S VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3900
Mailing Address - Country:US
Mailing Address - Phone:970-749-5023
Mailing Address - Fax:
Practice Address - Street 1:611 S VALLEY RD
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3900
Practice Address - Country:US
Practice Address - Phone:970-749-5023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-02
Last Update Date:2017-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications