Provider Demographics
NPI:1790979359
Name:MARTINEZ, MICHAEL J (CSA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 S WASHINGTON ST STE 204
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6675
Mailing Address - Country:US
Mailing Address - Phone:505-787-1013
Mailing Address - Fax:
Practice Address - Street 1:608 S WASHINGTON ST STE 204
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6675
Practice Address - Country:US
Practice Address - Phone:505-787-1013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3036282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital