Provider Demographics
NPI:1902418734
Name:MARTINEZ, WALTER IVAN
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:IVAN
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 1:11843 GILMORE ST APT 210
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-2857
Mailing Address - Country:US
Mailing Address - Phone:818-818-7362
Mailing Address - Fax:
Practice Address - Street 1:11843 GILMORE ST APT 210
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-2857
Practice Address - Country:US
Practice Address - Phone:818-818-7362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86972126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86972Medicaid