Provider Demographics
NPI:1871002659
Name:MARTINEZ, SAMUEL (RD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:260-266-2593
Mailing Address - Fax:
Practice Address - Street 1:11109 PARKVIEW PLAZA DR.
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46846
Practice Address - Country:US
Practice Address - Phone:260-266-2593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86049228133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered