Provider Demographics
NPI:1790923886
Name:MARTINEZ, MICHAEL SHAWN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHAWN
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 1:20094 MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-1237
Mailing Address - Country:US
Mailing Address - Phone:510-727-9755
Mailing Address - Fax:510-727-9761
Practice Address - Street 1:20094 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-1237
Practice Address - Country:US
Practice Address - Phone:510-727-9755
Practice Address - Fax:510-727-9761
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-27
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine