Provider Demographics
NPI:1932328663
Name:MARTINEZ, BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2253
Mailing Address - Country:US
Mailing Address - Phone:719-561-1291
Mailing Address - Fax:719-561-8660
Practice Address - Street 1:1726 S PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2253
Practice Address - Country:US
Practice Address - Phone:719-561-1291
Practice Address - Fax:719-561-8660
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01234939Medicaid
CO01234939Medicaid
COC811178Medicare PIN
COC58231Medicare PIN