Provider Demographics
NPI:1790794196
Name:MARTINDALE, JIMMY JUSTIN (MPT, OCS, FAAOMPT)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:JUSTIN
Last Name:MARTINDALE
Suffix:
Gender:M
Credentials:MPT, OCS, FAAOMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15502 HUEBNER RD STE 113
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-0984
Mailing Address - Country:US
Mailing Address - Phone:210-479-3334
Mailing Address - Fax:210-479-3338
Practice Address - Street 1:15502 HUEBNER RD STE 113
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78248-0984
Practice Address - Country:US
Practice Address - Phone:210-479-3334
Practice Address - Fax:210-479-3338
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1134740225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T4517OtherBCBS PROVIDER NUMBER
TX8T4517OtherBCBS PROVIDER NUMBER